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Get NM Credentials Application

E all that apply and for which you are currently licensed: MD DO DDS DC DPM OD PA CNM CNP CRNA RN PT OT ST DOrienMed Acup Clin Psych Psych Assoc LMHC LPAT LADAC LISW LMSW LPC LPCC LMFT CNS/Psych CNS/Medical Spch Path Other: Specialty: Gender: F M Citizenship: Place of Birth: Social Security Number: Date of Birth: State Tax ID#: Pending Federal Tax ID#: Pending Medicare #: Pending Medicaid #: Pending Pending Unique Physician Identification Number (UPIN): Office Manager or Contact P.

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