Healthcare Provider Details

I. General information

NPI: 1942326608
Provider Name (Legal Business Name): ELLEN WITTMAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELLEN ORR WITTMAN PA

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 HOSPITAL DR SUITE 200
SANTA FE NM
87505-4769
US

IV. Provider business mailing address

228 E CORDOVA RD
SANTA FE NM
87505-0660
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-3833
  • Fax:
Mailing address:
  • Phone: 505-982-3833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2006-0021
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: