Healthcare Provider Details

I. General information

NPI: 1730427014
Provider Name (Legal Business Name): DAVID COLLADO ESTABILLO FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2013
Last Update Date: 05/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W 21ST ST STE E3
CLOVIS NM
88101
US

IV. Provider business mailing address

PO BOX 1161
CLOVIS NM
88102-1161
US

V. Phone/Fax

Practice location:
  • Phone: 954-655-3570
  • Fax:
Mailing address:
  • Phone: 954-655-3570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number264709
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-18171
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02364
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: