Provider Demographics
NPI:1659303238
Name:JESSUP, MONICA ANDREA (DPM)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:ANDREA
Last Name:JESSUP
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:MONICA
Other - Middle Name:JESSUP
Other - Last Name:VANUWAVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:516 E. NIZHONI BLVD.
Mailing Address - Street 2:BOX 1337
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:505-722-1496
Practice Address - Street 1:516 E. NIZHONI BLVD.
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-1337
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-722-1496
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC451213E00000X
SC548213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ015586Medicaid
NM13022075Medicaid
V08547Medicare UPIN
AZ015586Medicaid
TX8HF062Medicare ID - Type UnspecifiedHSZ001