Provider Demographics
NPI:1558855650
Name:PROVENCIO, AMANDA BUSTAMANTE (MD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:BUSTAMANTE
Last Name:PROVENCIO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3811
Mailing Address - Country:US
Mailing Address - Phone:575-915-8821
Mailing Address - Fax:
Practice Address - Street 1:1240 S TELSHOR BLVD STE A
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4731
Practice Address - Country:US
Practice Address - Phone:575-915-8821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRS2018-0570207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine