=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508103268
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RONALD WAYNE RACCA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2013
-----------------------------------------------------
Last Update Date | 01/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12700 CALLE DEL OSO PL NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87111-8056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-345-1789
-----------------------------------------------------
Fax | 505-344-7875
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12700 CALLE DEL OSO PL NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87111-8056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0801X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Trauma Physician
-----------------------------------------------------
License Number | 74-226
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------