Healthcare Provider Details

I. General information

NPI: 1598058331
Provider Name (Legal Business Name): COURTNEY NICOLE MEINDERS P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COURTNEY NICOLE RICCI PA

II. Dates (important events)

Enumeration Date: 05/26/2011
Last Update Date: 05/19/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 ALAMEDA BLVD NE STE G
ALBUQUERQUE NM
87113-1591
US

IV. Provider business mailing address

4545 ALAMEDA BLVD NE STE G
ALBUQUERQUE NM
87113-1591
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-2900
  • Fax: 505-938-4198
Mailing address:
  • Phone: 505-896-2900
  • Fax: 505-938-4198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0004740
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00792
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2021-0032
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: