Basic Information
| Provider Information | |||||||||
| NPI: | 1629345848 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AL-RAIE | ||||||||
| FirstName: | MOHAMMAD | ||||||||
| MiddleName: | I. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 ENCINO PL NE STE D | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052247400 | ||||||||
| FaxNumber: | 5052247404 | ||||||||
| Practice Location | |||||||||
| Address1: | 8200 CENTRAL AVE SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871082408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052725885 | ||||||||
| FaxNumber: | 5052725888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2011 | ||||||||
| LastUpdateDate: | 06/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA2011-0027 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 27782093 | 05 | NM | MEDICAID |