Basic Information
| Provider Information | |||||||||
| NPI: | 1023013216 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEMELIN | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3411 N 5TH AVE | ||||||||
| Address2: | STE 209 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850133812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027890344 | ||||||||
| FaxNumber: | 6028707566 | ||||||||
| Practice Location | |||||||||
| Address1: | 8208 LOUISIANA BLVD NE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871131757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058581222 | ||||||||
| FaxNumber: | 5058581224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2005 | ||||||||
| LastUpdateDate: | 11/02/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2001PA01 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 000A7566 | 05 | NM | MEDICAID |