Provider Demographics
NPI:1104455286
Name:NEW MEXICO STATE UNIVERSITY
Entity type:Organization
Organization Name:NEW MEXICO STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXTENSION ASSOCIATE II
Authorized Official - Prefix:
Authorized Official - First Name:LUCINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANEGAS-CARREON
Authorized Official - Suffix:
Authorized Official - Credentials:MPH, CHES
Authorized Official - Phone:575-646-2034
Mailing Address - Street 1:P.O. BOX 30003
Mailing Address - Street 2:MSC 3AE
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88003
Mailing Address - Country:US
Mailing Address - Phone:575-646-2034
Mailing Address - Fax:
Practice Address - Street 1:940 COLLEGE DRIVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88003
Practice Address - Country:US
Practice Address - Phone:575-646-2034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW MEXICO STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty