Provider Demographics
NPI:1619392883
Name:SUPAN, RUBEN ALFARO (NP-C)
Entity Type:Individual
Prefix:MR
First Name:RUBEN
Middle Name:ALFARO
Last Name:SUPAN
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8244
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-8244
Mailing Address - Country:US
Mailing Address - Phone:575-624-2095
Mailing Address - Fax:
Practice Address - Street 1:405 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5209
Practice Address - Country:US
Practice Address - Phone:505-409-0831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-25
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP02032363LP0808X
NMCNP-02362363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty