Healthcare Provider Details

I. General information

NPI: 1083470116
Provider Name (Legal Business Name): NATHAN DUANE COGBURN FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 MUNICIPAL WAY
EDGEWOOD NM
87015-7210
US

IV. Provider business mailing address

86B MARTIN LN
MORIARTY NM
87035-5605
US

V. Phone/Fax

Practice location:
  • Phone: 505-281-3406
  • Fax:
Mailing address:
  • Phone: 505-249-8758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number78111
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: