Provider Demographics
NPI:1366773947
Name:UPPER VALLEY MEDICAL CLINIC, PLLC
Entity type:Organization
Organization Name:UPPER VALLEY MEDICAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LUCERO
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:915-877-4217
Mailing Address - Street 1:7250 NINTH ST
Mailing Address - Street 2:
Mailing Address - City:CANUTILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79835-6011
Mailing Address - Country:US
Mailing Address - Phone:915-877-4217
Mailing Address - Fax:915-877-4231
Practice Address - Street 1:950 ANTHONY ST
Practice Address - Street 2:
Practice Address - City:CANUTILLO
Practice Address - State:TX
Practice Address - Zip Code:79835-6052
Practice Address - Country:US
Practice Address - Phone:915-877-4217
Practice Address - Fax:915-877-4231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX537539363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty