Provider Demographics
NPI:1629345848
Name:AL-RAIE, MOHAMMAD I (PA)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:I
Last Name:AL-RAIE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 ENCINO PL NE STE D
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2650
Mailing Address - Country:US
Mailing Address - Phone:505-224-7400
Mailing Address - Fax:505-224-7404
Practice Address - Street 1:8200 CENTRAL AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2408
Practice Address - Country:US
Practice Address - Phone:505-272-5885
Practice Address - Fax:505-272-5888
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2011-0027363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM27782093Medicaid