Provider Demographics
NPI:1770597510
Name:LENTZ, MICHAEL E (PAC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:LENTZ
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 GIBSON BLVD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-4729
Mailing Address - Country:US
Mailing Address - Phone:505-262-7960
Mailing Address - Fax:505-232-1368
Practice Address - Street 1:5400 GIBSON SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108
Practice Address - Country:US
Practice Address - Phone:505-262-7594
Practice Address - Fax:505-262-7641
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM83-PA009363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S74688Medicare UPIN
NM92908Medicaid