Provider Demographics
NPI:1902524598
Name:BELTRAN, LOLA (PA-C)
Entity type:Individual
Prefix:
First Name:LOLA
Middle Name:
Last Name:BELTRAN
Suffix:
Gender:F
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:PO BOX 299
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-0299
Mailing Address - Country:US
Mailing Address - Phone:575-356-6652
Mailing Address - Fax:575-359-6827
Practice Address - Street 1:42121 US HWY 70
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-9347
Practice Address - Country:US
Practice Address - Phone:575-356-6652
Practice Address - Fax:575-359-6827
Is Sole Proprietor?:No
Enumeration Date:2022-08-18
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2024-0108363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant