Healthcare Provider Details

I. General information

NPI: 1750428819
Provider Name (Legal Business Name): MIGUEL PONCE CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 03/18/2023
Certification Date: 03/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N ROADRUNNER PKWY
LAS CRUCES NM
88011-7044
US

IV. Provider business mailing address

1009 CALLE PARQUE DR
EL PASO TX
79912-7502
US

V. Phone/Fax

Practice location:
  • Phone: 575-556-6440
  • Fax: 575-556-6445
Mailing address:
  • Phone: 915-241-6867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number66710
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number241536
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1071475
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number66710
License Number StateNM
# 5
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number66710
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: