Provider Demographics
NPI:1316915051
Name:MORA, PAULA RENEE (MD)
Entity type:Individual
Prefix:DR
First Name:PAULA
Middle Name:RENEE
Last Name:MORA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 E NIZHONI BLVD
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5748
Mailing Address - Country:US
Mailing Address - Phone:505-722-1482
Mailing Address - Fax:505-722-1629
Practice Address - Street 1:516 E NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5748
Practice Address - Country:US
Practice Address - Phone:505-722-1482
Practice Address - Fax:505-722-1629
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29216208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM21657025Medicaid
NM769614OtherAHCCCS
NM769614OtherAHCCCS
NMH40318Medicare UPIN
NM8HBJ84Medicare ID - Type Unspecified
NM769614OtherAHCCCS