MEDICARE: DR. TANIA D PENCE DO

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	207X00000X	Orthopaedic Surgery Physician	DR0056511	CO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
6	NM301797	OTHER	NM	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1649294125	OTHER	NM	BCBS
2	1649294125	OTHER	NM	CIGNA
3	1649294125	OTHER	NM	LOVELACE
4	202034211	OTHER	NM	PRESBYTRIAN HEALTH PLAN
5	A-1373-06	OTHER	NM	NM LICENSE
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649294125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TANIA D PENCE DO

Provider Business Mailing Address
First Line	:	105 MILLS AVE STE 200
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4169
Country	:	US
Telephone Number	:	505-426-3795
Fax Number	:	505-425-2653

Provider Business Practice Location Address
First Line	:	105 MILLS AVE STE 200
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4169
Country	:	US
Telephone Number	:	505-426-3795
Fax Number	:	505-425-2653

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

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	03/13/2023

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1841204294 — NEW MEXICO QUICKCARE MEDICAL GROUP
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1235247461 — THERESA OKORO CNM
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1003973397 — DR. G. MICHAEL LOPEZ M.D.
Practice Location Address:

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Directions to “ DR. TANIA D PENCE DO” Practice Location

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