Provider Demographics
NPI:1790991651
Name:WHEATLAND FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:WHEATLAND FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FERRALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-647-8366
Mailing Address - Street 1:PO BOX 1560
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88004-1560
Mailing Address - Country:US
Mailing Address - Phone:505-647-8366
Mailing Address - Fax:505-647-8381
Practice Address - Street 1:700 MEDICAL CENTER DR
Practice Address - Street 2:STE. 101
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-9013
Practice Address - Country:US
Practice Address - Phone:316-281-9504
Practice Address - Fax:316-281-9531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0431518207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS2005004134Medicare PIN