Healthcare Provider Details

I. General information

NPI: 1205826013
Provider Name (Legal Business Name): KALI MAE MENDOZA-WERNER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CARSON AVE SUITE 201
LA JUNTA CO
81050-2751
US

IV. Provider business mailing address

711 BARNES AVE
LA JUNTA CO
81050-2138
US

V. Phone/Fax

Practice location:
  • Phone: 719-383-5900
  • Fax: 719-383-6533
Mailing address:
  • Phone: 719-384-5446
  • Fax: 719-384-5672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number942
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: