Provider Demographics
NPI:1083485213
Name:PONCE, HECTOR ANIBAL SR (AGNP)
Entity Type:Individual
Prefix:
First Name:HECTOR
Middle Name:ANIBAL
Last Name:PONCE
Suffix:SR
Gender:M
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12848 TIERRA PUEBLO
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-4303
Mailing Address - Country:US
Mailing Address - Phone:915-217-6585
Mailing Address - Fax:
Practice Address - Street 1:3900 E LOHMAN AVE STE B
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8268
Practice Address - Country:US
Practice Address - Phone:575-522-5752
Practice Address - Fax:575-522-5722
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM77261363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner