Basic Information
| Provider Information | |||||||||
| NPI: | 1780080358 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | APODACA | ||||||||
| FirstName: | AUDRIANA | ||||||||
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| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 385 CALLE DE ALEGRA | ||||||||
| Address2: | BLDG. A | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755261105 | ||||||||
| FaxNumber: | 5755244266 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | SANTA TERESA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5758749338 | ||||||||
| FaxNumber: | 5758749359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2014 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
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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 | 363LP0200X | AP126833 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | CNP-02940 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 252452YRND | 01 | NM | MEDICARE | OTHER | 96479779 | 05 | NM | MEDICAID |