Healthcare Provider Details

I. General information

NPI: 1538844964
Provider Name (Legal Business Name): SEAN PAUL RONEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 01/25/2025
Certification Date: 01/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12529 ELAINE PL NE
ALBUQUERQUE NM
87112-3625
US

IV. Provider business mailing address

MSC 09 5040 1 UNM
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-615-6595
  • Fax:
Mailing address:
  • Phone: 505-272-9864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2025-0006
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: