Provider Demographics
NPI:1699790881
Name:JAQUEZ, LAURA SPROSTON (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:SPROSTON
Last Name:JAQUEZ
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 1:2130 FARMINGTON AVE STE A
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2123
Mailing Address - Country:US
Mailing Address - Phone:505-325-2323
Mailing Address - Fax:505-325-7172
Practice Address - Street 1:2130 FARMINGTON AVE STE A
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-325-2323
Practice Address - Fax:505-325-7172
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001-314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM24906255Medicaid
NMH14713Medicare UPIN
NM24906255Medicaid