Healthcare Provider Details

I. General information

NPI: 1083885560
Provider Name (Legal Business Name): LISA A WENTLING PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31039 HWY 64 # B
CIMARRON NM
87714-9646
US

IV. Provider business mailing address

PO BOX 625
CIMARRON NM
87714-0625
US

V. Phone/Fax

Practice location:
  • Phone: 575-376-2402
  • Fax:
Mailing address:
  • Phone: 575-376-2402
  • Fax: 575-376-2107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2008-0063
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0002467
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA2008-0063
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: