Healthcare Provider Details

I. General information

NPI: 1497266019
Provider Name (Legal Business Name): LISA ANN WERMELING PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 SAINT MICHAELS DR STE 116
SANTA FE NM
87505-7621
US

IV. Provider business mailing address

465 SAINT MICHAELS DR STE 116
SANTA FE NM
87505-7621
US

V. Phone/Fax

Practice location:
  • Phone: 505-913-4260
  • Fax: 505-913-4261
Mailing address:
  • Phone: 505-913-4260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2017-0089
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: