Healthcare Provider Details

I. General information

NPI: 1144716507
Provider Name (Legal Business Name): KYLE CLAYTON GABIOUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 S DON ROSER DR
LAS CRUCES NM
88011-9107
US

IV. Provider business mailing address

2545 S DON ROSER DR
LAS CRUCES NM
88011-9107
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-7880
  • Fax: 575-522-7226
Mailing address:
  • Phone: 575-522-7880
  • Fax: 755-227-2265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2018-0051
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: