Provider Demographics
NPI:1962628594
Name:CARRELLAS, JOAN LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:LOUISE
Last Name:CARRELLAS
Suffix:
Gender:F
Credentials:MD
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:ST. VINCENT HOSPITALIST GROUP
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7601
Mailing Address - Country:US
Mailing Address - Phone:505-989-6130
Mailing Address - Fax:
Practice Address - Street 1:455 SAINT MICHAELS DR
Practice Address - Street 2:ST. VINCENT HOSPITALIST GROUP
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7601
Practice Address - Country:US
Practice Address - Phone:505-989-6130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2007-0254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD3949Medicaid
AKH63991Medicare UPIN