Healthcare Provider Details

I. General information

NPI: 1639580749
Provider Name (Legal Business Name): NOELLE BAROODY PA-C, DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 E ROOSEVELT AVE
GRANTS NM
87020
US

IV. Provider business mailing address

1423 E ROOSEVELT AVE
GRANTS NM
87020-2245
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-6500
  • Fax: 505-287-5393
Mailing address:
  • Phone: 505-287-6500
  • Fax: 505-287-5393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1140
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA2022-0139
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: