Basic Information
| Provider Information | |||||||||
| NPI: | 1720416431 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOVIKOFF | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | THERESA | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LUCIC | ||||||||
| OtherFirstName: | MEGAN | ||||||||
| OtherMiddleName: | T. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 530 DE MOSS STREET | ||||||||
| Address2: | HIDALGO MEDICAL SERVICES | ||||||||
| City: | LORDSBURG | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880452618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755428384 | ||||||||
| FaxNumber: | 5755422388 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 SILVER STREET | ||||||||
| Address2: | HMS SHS WELLNESS CENTER | ||||||||
| City: | SILVER CITY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880617283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753881511 | ||||||||
| FaxNumber: | 5755422388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2013 | ||||||||
| LastUpdateDate: | 01/11/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 165097 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA2015-0013 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 60902230 | 05 | NM | MEDICAID |