Provider Demographics
NPI:1083885560
Name:WENTLING, LISA A (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:A
Last Name:WENTLING
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 625
Mailing Address - Street 2:
Mailing Address - City:CIMARRON
Mailing Address - State:NM
Mailing Address - Zip Code:87714-0625
Mailing Address - Country:US
Mailing Address - Phone:575-376-2402
Mailing Address - Fax:575-376-2107
Practice Address - Street 1:31039 HWY 64 # B
Practice Address - Street 2:
Practice Address - City:CIMARRON
Practice Address - State:NM
Practice Address - Zip Code:87714-9646
Practice Address - Country:US
Practice Address - Phone:575-376-2402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-12
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2008-0063207Q00000X
MDC0002467363AM0700X
NMPA2008-0063207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMCS00214130OtherPHARMACY
NMPA2008-0063OtherLICENSE
MDP44694Medicare UPIN