Provider Demographics
NPI:1912898354
Name:VARGAS, DESIRAE NICHOLE (CPSW)
Entity type:Individual
Prefix:
First Name:DESIRAE
Middle Name:NICHOLE
Last Name:VARGAS
Suffix:
Gender:F
Credentials:CPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4816 MCMAHON BLVD NW APT H64
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5051
Mailing Address - Country:US
Mailing Address - Phone:505-464-6266
Mailing Address - Fax:
Practice Address - Street 1:3301 LOS ARBOLES AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1943
Practice Address - Country:US
Practice Address - Phone:505-800-7092
Practice Address - Fax:505-888-2851
Is Sole Proprietor?:No
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1890175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist