Basic Information
| Provider Information | |||||||||
| NPI: | 1003062738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLEMENS | ||||||||
| FirstName: | AUDRA | ||||||||
| MiddleName: | DAWN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26028 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052627219 | ||||||||
| FaxNumber: | 5052321627 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 WALTER AVE NW | ||||||||
| Address2: | SUITE 510 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052623542 | ||||||||
| FaxNumber: | 5052627394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2008 | ||||||||
| LastUpdateDate: | 02/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2008-0015 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA2008-0015 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 27483754 | 05 | NM | MEDICAID |