Provider Demographics
NPI:1285192716
Name:MYERS, EDWIN GREGORY (DOM, LMT)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:GREGORY
Last Name:MYERS
Suffix:
Gender:M
Credentials:DOM, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 61 BOX 1012
Mailing Address - Street 2:
Mailing Address - City:RAMAH
Mailing Address - State:NM
Mailing Address - Zip Code:87321-9600
Mailing Address - Country:US
Mailing Address - Phone:505-490-7204
Mailing Address - Fax:
Practice Address - Street 1:4019 ICE CAVES ROAD
Practice Address - Street 2:
Practice Address - City:RAMAH
Practice Address - State:NM
Practice Address - Zip Code:87321
Practice Address - Country:US
Practice Address - Phone:505-490-7204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1240171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist