Provider Demographics
NPI:1679318166
Name:MACON, NATASHA
Entity type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:MACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 N POPE ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-5161
Mailing Address - Country:US
Mailing Address - Phone:575-597-2568
Mailing Address - Fax:575-313-8236
Practice Address - Street 1:1007 N POPE ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-5161
Practice Address - Country:US
Practice Address - Phone:575-597-2568
Practice Address - Fax:575-313-8236
Is Sole Proprietor?:No
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMG-1584172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker