Healthcare Provider Details

I. General information

NPI: 1629862289
Provider Name (Legal Business Name): KENNETH BARNCASTLE APRN-CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2025
Last Update Date: 04/08/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 E SKY LOOP
ROSWELL NM
88201-8336
US

IV. Provider business mailing address

13 E SKY LOOP
ROSWELL NM
88201-8336
US

V. Phone/Fax

Practice location:
  • Phone: 505-400-4143
  • Fax:
Mailing address:
  • Phone: 505-400-4143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number58900
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number58900
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number58900
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number58900
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: