Provider Demographics
NPI:1942326608
Name:WITTMAN, ELLEN (PA)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:
Last Name:WITTMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:ORR WITTMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:228 E CORDOVA RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-0660
Mailing Address - Country:US
Mailing Address - Phone:505-982-3833
Mailing Address - Fax:
Practice Address - Street 1:1650 HOSPITAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4769
Practice Address - Country:US
Practice Address - Phone:505-982-3833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2006-0021363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical