Provider Demographics
NPI:1447253927
Name:O'CONNELL, MICHAEL JEFFREY (CFNP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JEFFREY
Last Name:O'CONNELL
Suffix:
Gender:M
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 691
Mailing Address - Street 2:
Mailing Address - City:MESILLA
Mailing Address - State:NM
Mailing Address - Zip Code:88046-0691
Mailing Address - Country:US
Mailing Address - Phone:575-636-5019
Mailing Address - Fax:575-522-3415
Practice Address - Street 1:2435 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5029
Practice Address - Country:US
Practice Address - Phone:575-522-7798
Practice Address - Fax:575-522-3415
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR37541363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM016345OtherBLUE CROSS BLUE SHIELD
NMS9749Medicaid
NMS9749Medicaid