Provider Demographics
NPI:1194023671
Name:LUCERO, MICHELLE RENEE (PA-C)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:RENEE
Last Name:LUCERO
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 EUBANK BLVD NE STE D205
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3479
Mailing Address - Country:US
Mailing Address - Phone:505-234-6432
Mailing Address - Fax:505-234-6432
Practice Address - Street 1:4550 EUBANK BLVD NE STE D205
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3479
Practice Address - Country:US
Practice Address - Phone:505-234-6432
Practice Address - Fax:505-234-6432
Is Sole Proprietor?:No
Enumeration Date:2011-03-07
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-2326363A00000X
NM2000PA27363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant