Healthcare Provider Details

I. General information

NPI: 1285359190
Provider Name (Legal Business Name): EDWARD CHARLES GABALDON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 MAIN ST NE
LOS LUNAS NM
87031-7401
US

IV. Provider business mailing address

6100 WYETH DR SE
ALBUQUERQUE NM
87106-8016
US

V. Phone/Fax

Practice location:
  • Phone: 505-814-1995
  • Fax:
Mailing address:
  • Phone: 505-730-6733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number69205
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: