Healthcare Provider Details

I. General information

NPI: 1700514361
Provider Name (Legal Business Name): RYAN K WOOD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W 21ST ST
CLOVIS NM
88101-4151
US

IV. Provider business mailing address

1100 W 21ST ST
CLOVIS NM
88101-4151
US

V. Phone/Fax

Practice location:
  • Phone: 575-769-2345
  • Fax: 575-769-9013
Mailing address:
  • Phone: 575-769-2345
  • Fax: 575-769-9013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNA
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: