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General NPI Number Information
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NPI Number | 1609182310
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Entity Type | Individual
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Provider Name | KELLY LEE RAY PA-C
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Gender | Female
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Dates
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Enumeration Date | 08/19/2010
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Last Update Date | 08/15/2024
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Provider Practice Location Address
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Address Line | 1581 OLD HWY 66, UNIT 1
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City | EDGEWOOD, NM
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State | NM
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Zip | 87015
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Country | US
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Telephone | 505-286-2396
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Fax | 505-286-2398
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Provider Business Mailing Address
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Address Line | 13017 BLUECORN MAIDEN TRL NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87112-3730
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Country | US
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Telephone | 505-967-7609
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Fax | 505-312-7697
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA2010-0035
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License Number State | NM
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