Provider Demographics
NPI:1609182310
Name:RAY, KELLY LEE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LEE
Last Name:RAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13017 BLUECORN MAIDEN TRL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-3730
Mailing Address - Country:US
Mailing Address - Phone:505-967-7609
Mailing Address - Fax:505-312-7697
Practice Address - Street 1:10131 COORS BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4045
Practice Address - Country:US
Practice Address - Phone:505-433-4446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-19
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2010-0035363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM07533322Medicaid
1092393OtherNATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANT