Basic Information
| Provider Information | |||||||||
| NPI: | 1790252328 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MERELMAN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3001 BROADMOOR BLVD NE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871442100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059947000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11501 MONTGOMERY BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871112796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058141995 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2018 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0005715 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA2022-0060 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA.2022-0060 | 01 | NM | NM PHYSICIAN ASSISTANT LICENCE | OTHER | 9000170559 | 05 | CO | MEDICAID |