Provider Demographics
NPI:1235218462
Name:CARLOZZI, REBEKAH D (PA)
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:D
Last Name:CARLOZZI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1574
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201
Mailing Address - Country:US
Mailing Address - Phone:575-627-9500
Mailing Address - Fax:575-627-4127
Practice Address - Street 1:402 W. COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201
Practice Address - Country:US
Practice Address - Phone:575-627-9500
Practice Address - Fax:575-627-4127
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2005-0060363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM31538568Medicaid
344604703Medicare ID - Type Unspecified
NMNM301410Medicare PIN
NMQ63762Medicare UPIN
NM31538568Medicaid