Provider Demographics
NPI:1477057164
Name:ZAGON, AIMEE
Entity Type:Individual
Prefix:
First Name:AIMEE
Middle Name:
Last Name:ZAGON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W LUPITA RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4718
Mailing Address - Country:US
Mailing Address - Phone:505-984-3130
Mailing Address - Fax:505-984-3130
Practice Address - Street 1:4311 HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-1530
Practice Address - Country:US
Practice Address - Phone:505-827-8983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA-017207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine