Healthcare Provider Details

I. General information

NPI: 1851989305
Provider Name (Legal Business Name): LAUREL ESCANO LAUREL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2021
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 HOSPITAL DR
RATON NM
87740-2012
US

IV. Provider business mailing address

203 HOSPITAL DR
RATON NM
87740-2012
US

V. Phone/Fax

Practice location:
  • Phone: 575-445-3661
  • Fax: 575-445-7737
Mailing address:
  • Phone: 575-445-3661
  • Fax: 575-445-7737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number62500
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: