Provider Demographics
NPI:1386958825
Name:LICONA SANJUAN, VANESSA D (MD)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:D
Last Name:LICONA SANJUAN
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 1:500 WALTER ST NE
Mailing Address - Street 2:STE 401
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2563
Mailing Address - Country:US
Mailing Address - Phone:505-727-5910
Mailing Address - Fax:505-727-5939
Practice Address - Street 1:500 WALTER ST NE
Practice Address - Street 2:STE 401
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2563
Practice Address - Country:US
Practice Address - Phone:505-727-5910
Practice Address - Fax:505-727-5939
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2012-08672084N0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM98305522Medicaid
NM376728YR41Medicare PIN