Provider Demographics
NPI:1083470116
Name:COGBURN, NATHAN DUANE (FNP)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:DUANE
Last Name:COGBURN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86B MARTIN LN
Mailing Address - Street 2:
Mailing Address - City:MORIARTY
Mailing Address - State:NM
Mailing Address - Zip Code:87035-5605
Mailing Address - Country:US
Mailing Address - Phone:505-249-8758
Mailing Address - Fax:
Practice Address - Street 1:7 MUNICIPAL WAY
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015-7210
Practice Address - Country:US
Practice Address - Phone:505-281-3406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM78111363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily