Provider Demographics
NPI:1639580749
Name:BAROODY, NOELLE (PA-C, DOM)
Entity type:Individual
Prefix:DR
First Name:NOELLE
Middle Name:
Last Name:BAROODY
Suffix:
Gender:
Credentials:PA-C, DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 E ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-2245
Mailing Address - Country:US
Mailing Address - Phone:505-287-6500
Mailing Address - Fax:505-287-5393
Practice Address - Street 1:1423 E ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020
Practice Address - Country:US
Practice Address - Phone:505-287-6500
Practice Address - Fax:505-287-5393
Is Sole Proprietor?:No
Enumeration Date:2014-05-12
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1140171100000X
NMPA2022-0139363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No171100000XOther Service ProvidersAcupuncturist