Provider Demographics
NPI:1710580865
Name:VELASQUEZ-BACA, MEGAN JAYLYN (MSN-APRN)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:JAYLYN
Last Name:VELASQUEZ-BACA
Suffix:
Gender:F
Credentials:MSN-APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 305
Mailing Address - Street 2:
Mailing Address - City:BLANCO
Mailing Address - State:NM
Mailing Address - Zip Code:87412-0304
Mailing Address - Country:US
Mailing Address - Phone:505-516-4909
Mailing Address - Fax:
Practice Address - Street 1:114 ROAD 4599
Practice Address - Street 2:
Practice Address - City:BLANCO
Practice Address - State:NM
Practice Address - Zip Code:87412-8741
Practice Address - Country:US
Practice Address - Phone:505-516-4909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM62051363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty