Healthcare Provider Details

I. General information

NPI: 1558352963
Provider Name (Legal Business Name): EDWIN EMMANUEL NEBBLETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FOSTER LANE
RESERVE NM
87830-0710
US

IV. Provider business mailing address

2837 HIGHWAY 32
QUEMADO NM
87829-9118
US

V. Phone/Fax

Practice location:
  • Phone: 575-533-6456
  • Fax: 575-533-6767
Mailing address:
  • Phone: 575-313-6070
  • Fax: 575-754-5409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG152996
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number99-267
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: