Healthcare Provider Details

I. General information

NPI: 1366934382
Provider Name (Legal Business Name): ADRIAN RICKETTS DAVIES PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ADRIAN KELLY RICKETTS PA

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 JUAN TABO BLVD NE
ALBUQUERQUE NM
87112-3303
US

IV. Provider business mailing address

6419 BRISTOL HWY
PINEY FLATS TN
37686-5208
US

V. Phone/Fax

Practice location:
  • Phone: 505-281-5180
  • Fax: 505-702-8171
Mailing address:
  • Phone: 615-202-3359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1151615
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3603
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2026-0017
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC954
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: