Healthcare Provider Details

I. General information

NPI: 1790469799
Provider Name (Legal Business Name): TYLER KINSON PALBICKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 08/15/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 W D.L. INGRAM AVENUE BLDG. 1408
CANNON AFB NM
88103-5014
US

IV. Provider business mailing address

3517 ADENMOR CT APT 2B
CLOVIS NM
88101-3058
US

V. Phone/Fax

Practice location:
  • Phone: 575-784-2778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number37107
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: