Provider Demographics
NPI:1124406269
Name:INTERNAL MEDICINE PREMIUM HEALTH CARE PC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE PREMIUM HEALTH CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDI
Authorized Official - Middle Name:LASHEA GLASON
Authorized Official - Last Name:DARAG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-652-4426
Mailing Address - Street 1:525 E LOHMAN AVE
Mailing Address - Street 2:STE D
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-3394
Mailing Address - Country:US
Mailing Address - Phone:525-652-4426
Mailing Address - Fax:525-222-0025
Practice Address - Street 1:525 E LOHMAN AVE
Practice Address - Street 2:STE D
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3394
Practice Address - Country:US
Practice Address - Phone:525-652-4426
Practice Address - Fax:525-222-0025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-08
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2013-0836207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty