Healthcare Provider Details

I. General information

NPI: 1528586435
Provider Name (Legal Business Name): ROMILLY ORTIZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 10/05/2024
Certification Date: 10/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 MEDICINE HORSE DR
CANONCITO NM
87026
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-908-2307
  • Fax:
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2017-0045
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: