Healthcare Provider Details

I. General information

NPI: 1053999862
Provider Name (Legal Business Name): JOSE MANUEL LOZANO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2021
Last Update Date: 04/01/2021
Certification Date: 04/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 MCNUTT RD
SUNLAND PARK NM
88063-9038
US

IV. Provider business mailing address

12041 N BREEZE PL
EL PASO TX
79934-3430
US

V. Phone/Fax

Practice location:
  • Phone: 575-589-3620
  • Fax:
Mailing address:
  • Phone: 915-355-6244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License Number15000253
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: