Healthcare Provider Details

I. General information

NPI: 1023013216
Provider Name (Legal Business Name): RONALD J LEMELIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 11/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8208 LOUISIANA BLVD NE SUITE C
ALBUQUERQUE NM
87113-1757
US

IV. Provider business mailing address

3411 N 5TH AVE STE 209
PHOENIX AZ
85013-3812
US

V. Phone/Fax

Practice location:
  • Phone: 505-858-1222
  • Fax: 505-858-1224
Mailing address:
  • Phone: 602-789-0344
  • Fax: 602-870-7566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2001PA01
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: