Provider Demographics
NPI:1629600556
Name:NANEZ, RUBEN COSTALES (MT ASCP)
Entity Type:Individual
Prefix:
First Name:RUBEN
Middle Name:COSTALES
Last Name:NANEZ
Suffix:
Gender:M
Credentials:MT ASCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 WENDY LN
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007-5324
Mailing Address - Country:US
Mailing Address - Phone:575-649-1847
Mailing Address - Fax:
Practice Address - Street 1:661 WENDY LN
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88007-5324
Practice Address - Country:US
Practice Address - Phone:575-649-1847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-09
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMT175482246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist