Provider Demographics
NPI:1366411415
Name:WYNTER, RICARDO (PA-C)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:WYNTER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 NORTH MAIN
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-2830
Mailing Address - Country:US
Mailing Address - Phone:575-396-6611
Mailing Address - Fax:575-396-1454
Practice Address - Street 1:1600 NORTH MAIN
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-2830
Practice Address - Country:US
Practice Address - Phone:575-396-6611
Practice Address - Fax:575-396-1454
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103250363A00000X
NMPA2014-0096363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ44111Medicare UPIN
FLU4788BMedicare ID - Type UnspecifiedMEDICARE