Provider Demographics
NPI:1245267251
Name:TABOR, RICKEY I (CNP)
Entity type:Individual
Prefix:
First Name:RICKEY
Middle Name:I
Last Name:TABOR
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 NORTH MAIN
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-2813
Mailing Address - Country:US
Mailing Address - Phone:575-396-3529
Mailing Address - Fax:575-396-1454
Practice Address - Street 1:1600 NORTH MAIN
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-2813
Practice Address - Country:US
Practice Address - Phone:575-396-3529
Practice Address - Fax:575-396-1454
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR15408363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM89485262Medicaid
NMNMA100127Medicare Oscar/Certification
NM89485262Medicaid