Healthcare Provider Details

I. General information

NPI: 1083485213
Provider Name (Legal Business Name): HECTOR ANIBAL PONCE SR. AGNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2024
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 E LOHMAN AVE STE B
LAS CRUCES NM
88011-8268
US

IV. Provider business mailing address

12848 TIERRA PUEBLO
EL PASO TX
79938-4303
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-5752
  • Fax: 575-522-5722
Mailing address:
  • Phone: 915-217-6585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number77261
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: