| K Ellis PA | |
|
1209 Mountain Road Pl Ne # 4953 Albuquerque NM 87110-7845 | |
| (904) 252-3606 | |
| (505) 546-4325 |
| Full Name | K Ellis PA |
|---|---|
| Speciality | Nurse Practitioner |
| Location | 1209 Mountain Road Pl Ne # 4953, Albuquerque, New Mexico |
| Authorized Official Name and Position | Keisha Ellis (AUTHORIZED OFFICIAL/OWNER) |
| Authorized Official Contact | 9042523606 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| K Ellis PA 1209 Mountain Road Pl Ne # 4953 Albuquerque NM 87110-7845 Ph: (904) 252-3606 | K Ellis PA 1209 Mountain Road Pl Ne # 4953 Albuquerque NM 87110-7845 Ph: (904) 252-3606 |
| NPI Number | 1124885348 |
|---|---|
| Provider Enumeration Date | 03/04/2024 |
| Last Update Date | 09/10/2024 |
| Certification Date | 09/10/2024 |
| Medicare PECOS PAC ID | 9931548518 |
|---|---|
| Medicare Enrollment ID | O20240416000460 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1124885348 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | (NU) | Secondary |
| 363LP0808X | Nurse Practitioner - Psychiatric/mental Health | (NU) | Primary |
| Provider Name | Keisha Ellis |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1508318494 PECOS PAC ID: 3072898246 Enrollment ID: I20180926003432 |
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