Provider Demographics
NPI:1487648622
Name:VARGAS, JANIE (PA)
Entity type:Individual
Prefix:
First Name:JANIE
Middle Name:
Last Name:VARGAS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S DIAMOND AVE
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-3752
Mailing Address - Country:US
Mailing Address - Phone:575-546-4663
Mailing Address - Fax:505-443-8331
Practice Address - Street 1:300 S DIAMOND AVE
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-3752
Practice Address - Country:US
Practice Address - Phone:575-546-4663
Practice Address - Fax:575-546-4844
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2004-0009363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM26235587Medicaid
343512401Medicare ID - Type Unspecified
NM26235587Medicaid