Provider Demographics
NPI:1255895090
Name:LUJAN, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:LUJAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 310001-0670
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0670
Mailing Address - Country:US
Mailing Address - Phone:575-758-6966
Mailing Address - Fax:575-751-5210
Practice Address - Street 1:1090 GOAT SPRINGS ROAD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:575-758-6966
Practice Address - Fax:575-751-5210
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR61659163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK3543Medicaid