Healthcare Provider Details

I. General information

NPI: 1316259930
Provider Name (Legal Business Name): DEVIN DEAN WAHLEN D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2010
Last Update Date: 07/21/2022
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 W 21ST ST
CLOVIS NM
88101-4024
US

IV. Provider business mailing address

1820 W 21ST ST
CLOVIS NM
88101-4024
US

V. Phone/Fax

Practice location:
  • Phone: 208-351-4559
  • Fax:
Mailing address:
  • Phone: 575-935-3668
  • Fax: 575-935-3669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number349
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: