Provider Demographics
NPI:1225050651
Name:SCHAEFER, JULIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:SCHAEFER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 W APACHE ST
Mailing Address - Street 2:#A
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-3279
Mailing Address - Country:US
Mailing Address - Phone:505-325-9683
Mailing Address - Fax:
Practice Address - Street 1:2300 E 30TH ST
Practice Address - Street 2:BLDG B, SUITE 102
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8990
Practice Address - Country:US
Practice Address - Phone:505-324-1000
Practice Address - Fax:505-324-1199
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM#99-PA25363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM77719Medicaid
NMPROVP16197OtherCIMMARON SALUD
NMNM003000OtherBLUE CROSS
NM77719Medicaid
NMP04600Medicare UPIN
NMPA00025Medicare ID - Type Unspecified