Basic Information
| Provider Information | |||||||||
| NPI: | 1205826013 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MENDOZA-WERNER | ||||||||
| FirstName: | KALI | ||||||||
| MiddleName: | MAE | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 BARNES AVE | ||||||||
| Address2: | |||||||||
| City: | LA JUNTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810502138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193845446 | ||||||||
| FaxNumber: | 7193845672 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 CARSON AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LA JUNTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810502751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193835900 | ||||||||
| FaxNumber: | 7193836533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 04/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 942 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 840706945168 | 01 | CO | ROCKY MOUNTAIN HEALTH PLA | OTHER | P00231959 | 01 | TRAVELERS MEDICARE | OTHER |