Healthcare Provider Details

I. General information

NPI: 1710951959
Provider Name (Legal Business Name): JEREMY RICHARD KERSEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC09 5040 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-2100
US

IV. Provider business mailing address

3001 BROADMOOR BLVD NE
RIO RANCHO NM
87144-2100
US

V. Phone/Fax

Practice location:
  • Phone: 505-219-6614
  • Fax:
Mailing address:
  • Phone: 505-994-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2015-0047
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: