Healthcare Provider Details

I. General information

NPI: 1508103268
Provider Name (Legal Business Name): RONALD WAYNE RACCA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2013
Last Update Date: 01/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12700 CALLE DEL OSO PL NE
ALBUQUERQUE NM
87111-8056
US

IV. Provider business mailing address

12700 CALLE DEL OSO PL NE
ALBUQUERQUE NM
87111-8056
US

V. Phone/Fax

Practice location:
  • Phone: 505-345-1789
  • Fax: 505-344-7875
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number74-226
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: