Healthcare Provider Details

I. General information

NPI: 1437695327
Provider Name (Legal Business Name): EASTERN NEW MEXICO FOOT & ANKLE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2017
Last Update Date: 05/11/2021
Certification Date: 05/11/2021
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:

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: DEVIN DEAN WAHLEN
Title or Position: PHYSICIAN/OWNER
Credential:
Phone: 575-935-3668