Provider Demographics
NPI:1790466381
Name:ORTIZ, WANDALISA (MD)
Entity Type:Individual
Prefix:
First Name:WANDALISA
Middle Name:
Last Name:ORTIZ
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:URB. TURABO GARDENS 3RA SECC.
Mailing Address - Street 2:CALLE A R-1525
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00727-5925
Mailing Address - Country:US
Mailing Address - Phone:787-378-2735
Mailing Address - Fax:
Practice Address - Street 1:URB. TURABO GARDENS 3RA SECC.
Practice Address - Street 2:CALLE A R-1525
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00727-5925
Practice Address - Country:US
Practice Address - Phone:787-378-2735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR001828363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical