Healthcare Provider Details

I. General information

NPI: 1811651136
Provider Name (Legal Business Name): SAMWEL RORYA NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2021
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 ASHFORD DR
CLOVIS NM
88101-4436
US

IV. Provider business mailing address

906 PEARSON DR
ROSWELL NM
88201-1168
US

V. Phone/Fax

Practice location:
  • Phone: 575-935-6398
  • Fax: 575-935-6399
Mailing address:
  • Phone: 316-305-4778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number65392
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: