Healthcare Provider Details

I. General information

NPI: 1275176141
Provider Name (Legal Business Name): KELLEY RUTTER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR. SE MEDICINE SERVICE (111)
ALBUQUERQUE NM
87108
US

IV. Provider business mailing address

1501 SAN PEDRO DR. SE MEDICINE SERVICE (111)
ALBUQUERQUE NM
87108
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2019-0090
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: