1972518637 NPI number — LAURA J. VISANKO MOTR/L

Table of content: LAURA J. VISANKO MOTR/L (NPI 1972518637)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972518637 NPI number — LAURA J. VISANKO MOTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VISANKO
Provider First Name:
LAURA
Provider Middle Name:
J.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MOTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972518637
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4151 CAMINO COYOTE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88011-7096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-522-0484
Provider Business Mailing Address Fax Number:
575-522-0483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4151 CAMINO COYOTE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88011-5111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-522-0484
Provider Business Practice Location Address Fax Number:
575-522-0483
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XH1200X , with the licence number:  731 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PROVP16915 . This is a "MOLINA HEALTH PLAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 79400507 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: NM00Q038 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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