Provider Demographics
NPI:1801813845
Name:EDGOOSE, JENNIFER Y C (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:Y C
Last Name:EDGOOSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Mailing Address - Street 2:MSC09 9040
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-272-4823
Mailing Address - Fax:
Practice Address - Street 1:2400 TUCKER AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-3935
Practice Address - Country:US
Practice Address - Phone:505-272-1734
Practice Address - Fax:505-272-1736
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI54451-020207Q00000X
NMMD2024-0740207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine