Provider Demographics
NPI:1568418697
Name:LUCHETTI, CELINA M (PA-C)
Entity Type:Individual
Prefix:
First Name:CELINA
Middle Name:M
Last Name:LUCHETTI
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 1:455 SAINT MICHAELS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7601
Mailing Address - Country:US
Mailing Address - Phone:505-802-5227
Mailing Address - Fax:
Practice Address - Street 1:490A W ZIA RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6996
Practice Address - Country:US
Practice Address - Phone:505-988-3975
Practice Address - Fax:505-986-8001
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2003-0030363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM22537082Medicaid
PROVP14189OtherMOLINA
10012822OtherLOVELACE
NMQ02855Medicare UPIN