Provider Demographics
NPI:1083962385
Name:JUAN N SOSA PHD PA
Entity Type:Organization
Organization Name:JUAN N SOSA PHD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:SOSA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:575-522-8002
Mailing Address - Street 1:1155 S TELSHOR BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-1009
Mailing Address - Country:US
Mailing Address - Phone:575-522-8002
Mailing Address - Fax:575-522-8027
Practice Address - Street 1:1155 S TELSHOR BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-1009
Practice Address - Country:US
Practice Address - Phone:575-522-8002
Practice Address - Fax:575-522-8027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-17
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM163251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN5806Medicaid