Provider Demographics
NPI:1023013216
Name:LEMELIN, RONALD J (PA-C)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:J
Last Name:LEMELIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3411 N 5TH AVE
Mailing Address - Street 2:STE 209
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3812
Mailing Address - Country:US
Mailing Address - Phone:602-789-0344
Mailing Address - Fax:602-870-7566
Practice Address - Street 1:8208 LOUISIANA BLVD NE
Practice Address - Street 2:SUITE C
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-1757
Practice Address - Country:US
Practice Address - Phone:505-858-1222
Practice Address - Fax:505-858-1224
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001PA01363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000A7566Medicaid
P24922Medicare UPIN
NM401922YNMTMedicare PIN
NM346724301Medicare PIN