Provider Demographics
NPI:1487648622
Name:VARGAS, JANIE (PA)
Entity Type:Individual
Prefix:
First Name:JANIE
Middle Name:
Last Name:VARGAS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 DE MOSS ST
Mailing Address - Street 2:
Mailing Address - City:LORDSBURG
Mailing Address - State:NM
Mailing Address - Zip Code:88045-2618
Mailing Address - Country:US
Mailing Address - Phone:575-542-8384
Mailing Address - Fax:575-542-8387
Practice Address - Street 1:2743B HIGHWAY 35
Practice Address - Street 2:
Practice Address - City:MIMBRES
Practice Address - State:NM
Practice Address - Zip Code:88049
Practice Address - Country:US
Practice Address - Phone:575-536-3990
Practice Address - Fax:575-536-3991
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2004-0009363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM26235587Medicaid
343512401Medicare ID - Type Unspecified
NM26235587Medicaid