Healthcare Provider Details

I. General information

NPI: 1083551766
Provider Name (Legal Business Name): MR. EDGAR YBANEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9932 BRUNSWICK PL NW
ALBUQUERQUE NM
87114-2153
US

IV. Provider business mailing address

9932 BRUNSWICK PL NW
ALBUQUERQUE NM
87114-2153
US

V. Phone/Fax

Practice location:
  • Phone: 505-400-9163
  • Fax:
Mailing address:
  • Phone: 505-400-9163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number90445
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: