Provider Demographics
NPI:1306264031
Name:MONTOYA, EDITH S
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:S
Last Name:MONTOYA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EDITH
Other - Middle Name:S
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:HATCH
Mailing Address - State:NM
Mailing Address - Zip Code:87937-0370
Mailing Address - Country:US
Mailing Address - Phone:575-267-3280
Mailing Address - Fax:575-267-1747
Practice Address - Street 1:1600 THORPE RD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88012-9776
Practice Address - Country:US
Practice Address - Phone:575-382-9292
Practice Address - Fax:575-382-2061
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18677037Medicaid