Provider Demographics
NPI:1891788253
Name:RIEDEL, ELIZABETH J (PA-C)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:J
Last Name:RIEDEL
Suffix:
Gender:F
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:PO BOX 158
Mailing Address - Street 2:538 N. PASEO DE ONATE
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0158
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-753-5815
Practice Address - Street 1:1111 EL LLANO RD
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-6727
Practice Address - Country:US
Practice Address - Phone:505-929-1629
Practice Address - Fax:505-753-5815
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM77-PA007363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM400315OtherMEDICARE PTAN
NM92726Medicaid