Provider Demographics
NPI:1548253594
Name:OSBORN, WENDELL MARC (CNP)
Entity type:Individual
Prefix:MR
First Name:WENDELL
Middle Name:MARC
Last Name:OSBORN
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4086
Mailing Address - Country:US
Mailing Address - Phone:575-935-7777
Mailing Address - Fax:575-935-7778
Practice Address - Street 1:2021 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4086
Practice Address - Country:US
Practice Address - Phone:575-935-7777
Practice Address - Fax:575-935-7778
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR31435363L00000X
NMCNP00646207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner