Provider Demographics
NPI:1497849871
Name:LEE, CARISA A (MD)
Entity Type:Individual
Prefix:
First Name:CARISA
Middle Name:A
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:PMG OB HOSPITALIST
Practice Address - Street 2:201 CEDAR SE SUITE 507
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:505-563-6381
Practice Address - Fax:505-563-6380
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0686208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM46534351Medicaid
NM46534351Medicaid
345604701Medicare PIN