Provider Demographics
NPI:1659368256
Name:VEGA, AUDREY (MD)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:VEGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 W COUNTRY CLUB RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5222
Mailing Address - Country:US
Mailing Address - Phone:575-622-1841
Mailing Address - Fax:575-622-5317
Practice Address - Street 1:350 W COUNTRY CLUB RD STE 101
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5222
Practice Address - Country:US
Practice Address - Phone:575-622-1841
Practice Address - Fax:575-622-5317
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM95-151207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME8609Medicaid
NMNPI & TINOtherBCBS OF NM
NMNPI & TINOtherBCBS OF NM
NME8609Medicaid