Provider Demographics
NPI:1003065749
Name:ANCONA, MARTIN NICHOLAS (PHD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:NICHOLAS
Last Name:ANCONA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 ANTHONY DRIVE
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:NM
Mailing Address - Zip Code:88021-9747
Mailing Address - Country:US
Mailing Address - Phone:575-882-5100
Mailing Address - Fax:
Practice Address - Street 1:320 MCCOMBS RD STE C
Practice Address - Street 2:
Practice Address - City:CHAPARRAL
Practice Address - State:NM
Practice Address - Zip Code:88081-7937
Practice Address - Country:US
Practice Address - Phone:575-882-5100
Practice Address - Fax:575-882-1151
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60201752103T00000X
NM1296103TC0700X
NM0040C103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical