MEDICARE: MAYEDEL SAN JOSE DNP, APRN, FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	AP130851	TX
2	363LF0000X	Family Nurse Practitioner	CNP-03155	NM

General Provider Information

NPI Number	:	1588018832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYEDEL SAN JOSE DNP, APRN, FNP-C

Provider Business Mailing Address
First Line	:	1245 COUNTRY CLUB RD STE 200
Second Line	:
City	:	SANTA TERESA
State	:	NM
Zip	:	88008-9743
Country	:	US
Telephone Number	:	575-332-4633
Fax Number	:

Provider Business Practice Location Address
First Line	:	1245 COUNTRY CLUB RD STE 200
Second Line	:
City	:	SANTA TERESA
State	:	NM
Zip	:	88008-9743
Country	:	US
Telephone Number	:	575-332-4633
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2016
Last Update Date	:	12/11/2024

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