Provider Demographics
NPI:1174749014
Name:AGOSTA, JENNIFER (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:AGOSTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4351 E LOHMAN AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8262
Mailing Address - Country:US
Mailing Address - Phone:575-556-3240
Mailing Address - Fax:575-522-3092
Practice Address - Street 1:4351 E LOHMAN AVE STE 320
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8262
Practice Address - Country:US
Practice Address - Phone:575-556-3240
Practice Address - Fax:575-522-3092
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2008-0157207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM570315YY54OtherMEDICARE ID
NM29380049Medicaid