Healthcare Provider Details

I. General information

NPI: 1598621278
Provider Name (Legal Business Name): CALSEY COWBOY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2025
Last Update Date: 12/26/2025
Certification Date: 12/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 E HISTORIC HIGHWAY 66
GALLUP NM
87301-5466
US

IV. Provider business mailing address

1108 E HISTORIC HIGHWAY 66
GALLUP NM
87301-5466
US

V. Phone/Fax

Practice location:
  • Phone: 505-726-9642
  • Fax: 800-507-4193
Mailing address:
  • Phone: 505-726-9642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: