Healthcare Provider Details

I. General information

NPI: 1689852196
Provider Name (Legal Business Name): THEODORE B GELLERT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TED B GELLERT PA-C

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE MSC10-5610 2-ACC
ALBUQUERQUE NM
87106-2745
US

IV. Provider business mailing address

800 SALAMANCA ST NW
LOS RANCHOS DE ALBUQUERQUE NM
87107-5620
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-6901
  • Fax:
Mailing address:
  • Phone: 505-345-0330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA2007-0036
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: