Provider Demographics
NPI:1154918381
Name:WATKINS, KELLI SUZANNE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:SUZANNE
Last Name:WATKINS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:LIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQEURQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:
Practice Address - Street 1:2400 UNSER BLVD SE STE 19400
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4740
Practice Address - Country:US
Practice Address - Phone:505-253-6100
Practice Address - Fax:505-253-6179
Is Sole Proprietor?:No
Enumeration Date:2020-12-22
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2020-0113363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM76328503Medicaid