Healthcare Provider Details

I. General information

NPI: 1104410331
Provider Name (Legal Business Name): MOSES BULAMBO PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2021
Last Update Date: 02/28/2021
Certification Date: 02/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 W AVENUE D
LOVINGTON NM
88260-3808
US

IV. Provider business mailing address

613 W 2ND ST STE 5
ROSWELL NM
88201-4671
US

V. Phone/Fax

Practice location:
  • Phone: 575-425-6045
  • Fax:
Mailing address:
  • Phone: 575-840-4888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number62667
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: