Healthcare Provider Details

I. General information

NPI: 1457781759
Provider Name (Legal Business Name): MATTHEW LAUMBACH MPAS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2013
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42121 US HIGHWAY 70
PORTALES NM
88130-9054
US

IV. Provider business mailing address

PO BOX 299
PORTALES NM
88130-0299
US

V. Phone/Fax

Practice location:
  • Phone: 575-356-6652
  • Fax: 575-359-6827
Mailing address:
  • Phone: 575-356-6652
  • Fax: 575-359-6827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2013-0063
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: