Provider Demographics
NPI:1285359190
Name:GABALDON, EDWARD CHARLES
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:CHARLES
Last Name:GABALDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 WYETH DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-8016
Mailing Address - Country:US
Mailing Address - Phone:505-730-6733
Mailing Address - Fax:
Practice Address - Street 1:1044 MAIN ST NE
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7401
Practice Address - Country:US
Practice Address - Phone:505-814-1995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM69205363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily