Provider Demographics
NPI:1437695327
Name:EASTERN NEW MEXICO FOOT & ANKLE, PC
Entity Type:Organization
Organization Name:EASTERN NEW MEXICO FOOT & ANKLE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEVIN
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:WAHLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-935-3668
Mailing Address - Street 1:1820 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4024
Mailing Address - Country:US
Mailing Address - Phone:575-935-3668
Mailing Address - Fax:
Practice Address - Street 1:1820 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4024
Practice Address - Country:US
Practice Address - Phone:208-351-4559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-16
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM349213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty