Healthcare Provider Details

I. General information

NPI: 1194023671
Provider Name (Legal Business Name): MICHELLE RENEE LUCERO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2011
Last Update Date: 04/11/2025
Certification Date: 04/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 EUBANK BLVD NE STE D205
ALBUQUERQUE NM
87111-3479
US

IV. Provider business mailing address

4550 EUBANK BLVD NE STE D205
ALBUQUERQUE NM
87111-3479
US

V. Phone/Fax

Practice location:
  • Phone: 505-234-6432
  • Fax: 505-234-6432
Mailing address:
  • Phone: 505-234-6432
  • Fax: 505-234-6432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-2326
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2000PA27
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: