Basic Information
Provider Information
NPI: 1003489329
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MONDRAGON
FirstName: LAKASEY
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: BT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1350 HILLRISE CIR
Address2:  
City: LAS CRUCES
State: NM
PostalCode: 880114759
CountryCode: US
TelephoneNumber: 5755229500
FaxNumber: 5756524163
Practice Location
Address1: 201 E LLANO ESTACADO BLVD
Address2:  
City: CLOVIS
State: NM
PostalCode: 881013708
CountryCode: US
TelephoneNumber: 5757639517
FaxNumber: 5757422369
Other Information
ProviderEnumerationDate: 07/23/2021
LastUpdateDate: 07/23/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 07/23/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X  Y    

No ID Information.


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