Provider Demographics
NPI:1811765316
Name:ENTZMINGER, TREVOR W (CNP)
Entity type:Individual
Prefix:MR
First Name:TREVOR
Middle Name:W
Last Name:ENTZMINGER
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 ASPENGLOW BLVD UNIT D
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-0705
Mailing Address - Country:US
Mailing Address - Phone:602-695-0798
Mailing Address - Fax:
Practice Address - Street 1:26 NARROW GAUGE RD
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528-5142
Practice Address - Country:US
Practice Address - Phone:575-419-0931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM77086363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health