Provider Demographics
NPI:1679028468
Name:RAY, MICHAEL (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:RAY
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3436 ISLETA BLVD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-5837
Mailing Address - Country:US
Mailing Address - Phone:505-462-7777
Mailing Address - Fax:
Practice Address - Street 1:1900 E HISTORIC HIGHWAY 66 STE 1
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-4883
Practice Address - Country:US
Practice Address - Phone:505-324-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-22
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-03028363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily