Provider Demographics
NPI:1689852196
Name:GELLERT, THEODORE B (PA-C)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:B
Last Name:GELLERT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:TED
Other - Middle Name:B
Other - Last Name:GELLERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:800 SALAMANCA ST NW
Mailing Address - Street 2:
Mailing Address - City:LOS RANCHOS DE ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5620
Mailing Address - Country:US
Mailing Address - Phone:505-345-0330
Mailing Address - Fax:
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:MSC10-5610 2-ACC
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2745
Practice Address - Country:US
Practice Address - Phone:505-272-6901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2007-0036363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM995993OtherUNMH