Basic Information
| Provider Information | |||||||||
| NPI: | 1053375212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1112 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882015010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756274200 | ||||||||
| FaxNumber: | 5756274212 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 E MESCALERO RD | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882016542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757552272 | ||||||||
| FaxNumber: | 5756223325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 87-381 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 330095YM5A | 01 | NM | MEDICARE PTAN | OTHER | 34684565 | 05 | NM | MEDICAID |