Healthcare Provider Details

I. General information

NPI: 1295659332
Provider Name (Legal Business Name): GAVYN ZANE YARBROUGH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 RIM VIEW RD
RANCHOS DE TAOS NM
87557
US

IV. Provider business mailing address

PO BOX 1748
RANCHOS DE TAOS NM
87557-1748
US

V. Phone/Fax

Practice location:
  • Phone: 505-633-0733
  • Fax: 505-472-8122
Mailing address:
  • Phone: 505-633-0733
  • Fax: 505-472-8122

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: