Provider Demographics
NPI:1225021389
Name:LUGO, FERNANDO
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:LUGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:HATCH
Mailing Address - State:NM
Mailing Address - Zip Code:87937-0370
Mailing Address - Country:US
Mailing Address - Phone:505-267-3088
Mailing Address - Fax:505-267-1747
Practice Address - Street 1:255 HWY 187
Practice Address - Street 2:
Practice Address - City:HATCH
Practice Address - State:NM
Practice Address - Zip Code:87937-0370
Practice Address - Country:US
Practice Address - Phone:505-267-3088
Practice Address - Fax:505-267-1747
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA1188-02207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM01625527Medicaid
NM01625527Medicaid