Provider Demographics
NPI:1558877290
Name:WERTZ, PAUL (RN-BSN)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:WERTZ
Suffix:
Gender:M
Credentials:RN-BSN
Other - Prefix:MR
Other - First Name:RICHARD
Other - Middle Name:PAUL
Other - Last Name:WERTZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS
Mailing Address - State:CO
Mailing Address - Zip Code:81152-0099
Mailing Address - Country:US
Mailing Address - Phone:719-672-3465
Mailing Address - Fax:719-672-3856
Practice Address - Street 1:233 MAIN STREET, SUITE C.
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:CO
Practice Address - Zip Code:81152-8115
Practice Address - Country:US
Practice Address - Phone:719-672-3465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1616934163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000190429Medicaid