Provider Demographics
NPI:1306948658
Name:PONCIK, WANDA J (FNP)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:J
Last Name:PONCIK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 CALLE DE ALEGRA
Mailing Address - Street 2:BLDG. A
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3417
Mailing Address - Country:US
Mailing Address - Phone:575-526-1105
Mailing Address - Fax:575-524-4266
Practice Address - Street 1:2625 MCNUTT RD.
Practice Address - Street 2:
Practice Address - City:SUNLAND PARK
Practice Address - State:NM
Practice Address - Zip Code:88063-9019
Practice Address - Country:US
Practice Address - Phone:575-589-0887
Practice Address - Fax:575-589-0898
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX508505363LF0000X
NMCNP01117363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM32085273Medicaid
NM32085273Medicaid
NMQ39217Medicare UPIN