Provider Demographics
NPI:1659927283
Name:NDOUR, NDEYE
Entity Type:Individual
Prefix:
First Name:NDEYE
Middle Name:
Last Name:NDOUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 RALPH BOONE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-9027
Mailing Address - Country:US
Mailing Address - Phone:703-347-3078
Mailing Address - Fax:
Practice Address - Street 1:2100 N M.L.K. JR BLVD
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:575-769-2141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM57121367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM127222Medicaid