Basic Information
| Provider Information | |||||||||
| NPI: | 1982113445 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUDINGTON | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | IVAN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12127B HWY 14 N | ||||||||
| Address2: | STE 5 | ||||||||
| City: | CEDAR CREST | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870089499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052815180 | ||||||||
| FaxNumber: | 5052815320 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 QUAIL TRAIL | ||||||||
| Address2: | UNIT B | ||||||||
| City: | EDGEWOOD | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052080204 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2017 | ||||||||
| LastUpdateDate: | 05/09/2019 | ||||||||
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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 | 363LF0000X | CNP-03395 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.