Provider Demographics
NPI:1609182310
Name:RAY, KELLY LEE (PA-C)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LEE
Last Name:RAY
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:13017 BLUECORN MAIDEN TRL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-3730
Mailing Address - Country:US
Mailing Address - Phone:505-967-7609
Mailing Address - Fax:505-312-7697
Practice Address - Street 1:1581 OLD HWY 66, UNIT 1
Practice Address - Street 2:
Practice Address - City:EDGEWOOD, NM
Practice Address - State:NM
Practice Address - Zip Code:87015
Practice Address - Country:US
Practice Address - Phone:505-286-2396
Practice Address - Fax:505-286-2398
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-19
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMPA2010-0035363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM07533322Medicaid
1092393OtherNATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANT