Provider Demographics
NPI:1205826013
Name:MENDOZA-WERNER, KALI MAE (PAC)
Entity Type:Individual
Prefix:
First Name:KALI
Middle Name:MAE
Last Name:MENDOZA-WERNER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 BARNES AVE
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-2138
Mailing Address - Country:US
Mailing Address - Phone:719-384-5446
Mailing Address - Fax:719-384-5672
Practice Address - Street 1:1100 CARSON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-2751
Practice Address - Country:US
Practice Address - Phone:719-383-5900
Practice Address - Fax:719-383-6533
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO942363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO840706945168OtherROCKY MOUNTAIN HEALTH PLA
P00231959OtherTRAVELERS MEDICARE
P46584Medicare UPIN
P00231959OtherTRAVELERS MEDICARE