Provider Demographics
NPI:1750428819
Name:PONCE, MIGUEL (CNP)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:PONCE
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 CALLE PARQUE DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-7502
Mailing Address - Country:US
Mailing Address - Phone:915-241-6867
Mailing Address - Fax:
Practice Address - Street 1:150 N ROADRUNNER PKWY
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-7044
Practice Address - Country:US
Practice Address - Phone:575-556-6440
Practice Address - Fax:575-556-6445
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2023-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM66710207XS0117X, 363LF0000X, 363AS0400X
TX241536208600000X
TX1071475363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0067KEOtherBCBS