Healthcare Provider Details

I. General information

NPI: 1790252328
Provider Name (Legal Business Name): KIMBERLY MARIE MERELMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2018
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 DR MARTIN LUTHER KING JR AVE NE STE 301
ALBUQUERQUE NM
87102-3668
US

IV. Provider business mailing address

715 DR MARTIN LUTHER KING JR AVE NE STE 301
ALBUQUERQUE NM
87102-3668
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-7090
  • Fax: 505-727-9590
Mailing address:
  • Phone: 505-727-7090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0005715
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2022-0060
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: