Provider Demographics
NPI:1528586435
Name:ORTIZ, ROMILLY (PA)
Entity Type:Individual
Prefix:
First Name:ROMILLY
Middle Name:
Last Name:ORTIZ
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 1:3813 FLORA VISTA AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-5132
Mailing Address - Country:US
Mailing Address - Phone:505-227-5969
Mailing Address - Fax:
Practice Address - Street 1:129 MEDICINE HORSE DR
Practice Address - Street 2:
Practice Address - City:CANONCITO
Practice Address - State:NM
Practice Address - Zip Code:87026
Practice Address - Country:US
Practice Address - Phone:505-908-2307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2017-0045363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant