Provider Demographics
NPI:1316259930
Name:WAHLEN, DEVIN DEAN (DPM)
Entity type:Individual
Prefix:DR
First Name:DEVIN
Middle Name:DEAN
Last Name:WAHLEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4024
Mailing Address - Country:US
Mailing Address - Phone:575-935-3668
Mailing Address - Fax:575-935-3669
Practice Address - Street 1:1820 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4024
Practice Address - Country:US
Practice Address - Phone:208-351-4559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM349213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM68923236Medicaid
NM299092YSGWMedicare PIN