Provider Demographics
NPI:1558352963
Name:NEBBLETT, EDWIN EMMANUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:EMMANUEL
Last Name:NEBBLETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2837 HIGHWAY 32
Mailing Address - Street 2:
Mailing Address - City:QUEMADO
Mailing Address - State:NM
Mailing Address - Zip Code:87829-9118
Mailing Address - Country:US
Mailing Address - Phone:575-313-6070
Mailing Address - Fax:575-754-5409
Practice Address - Street 1:1 FOSTER LANE
Practice Address - Street 2:
Practice Address - City:RESERVE
Practice Address - State:NM
Practice Address - Zip Code:87830-0710
Practice Address - Country:US
Practice Address - Phone:575-533-6456
Practice Address - Fax:575-533-6767
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG152996207Q00000X
NM99-267207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM99-267OtherSTATE LICENSE
CAFN7464441OtherCA DEA
NM99-267OtherSTATE LICENSE