Healthcare Provider Details

I. General information

NPI: 1619392883
Provider Name (Legal Business Name): RUBEN ALFARO SUPAN NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W COUNTRY CLUB RD
ROSWELL NM
88201-5209
US

IV. Provider business mailing address

PO BOX 8244
ROSWELL NM
88202-8244
US

V. Phone/Fax

Practice location:
  • Phone: 505-409-0831
  • Fax:
Mailing address:
  • Phone: 575-624-2095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP02032
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02362
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: