Healthcare Provider Details

I. General information

NPI: 1043978372
Provider Name (Legal Business Name): MORIAH CARTY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2021
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CENTRAL AVE SE
ALBUQUERQUE NM
87106-4930
US

IV. Provider business mailing address

5729 EDITH BLVD NE APT C
ALBUQUERQUE NM
87107-5163
US

V. Phone/Fax

Practice location:
  • Phone: 505-724-6124
  • Fax:
Mailing address:
  • Phone: 505-999-7543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2021-0116
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: