Provider Demographics
NPI:1962690826
Name:ARAGON, SAMUEL A
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:A
Last Name:ARAGON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HWY 518 RANGER RD.
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:NM
Mailing Address - Zip Code:87773
Mailing Address - Country:US
Mailing Address - Phone:505-387-3113
Mailing Address - Fax:
Practice Address - Street 1:HWY 518 RANGER RD.
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:NM
Practice Address - Zip Code:87773
Practice Address - Country:US
Practice Address - Phone:505-387-3113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-08651041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM15700763Medicaid