Basic Information
| Provider Information | |||||||||
| NPI: | 1750936522 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUJAN | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | APRN-CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 PASEO DE PERALTA | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875011860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059882449 | ||||||||
| FaxNumber: | 5058190588 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 W PRAIRIE AVE | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838158780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082090288 | ||||||||
| FaxNumber: | 2082090289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2019 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 57250 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 71672 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.