Provider Demographics
NPI:1154897031
Name:MENDOZA GOMEZ, REBECA J
Entity type:Individual
Prefix:
First Name:REBECA
Middle Name:J
Last Name:MENDOZA GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1008
Mailing Address - Country:US
Mailing Address - Phone:801-822-2234
Mailing Address - Fax:505-281-5320
Practice Address - Street 1:1401 WILLIAM ST SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-4661
Practice Address - Country:US
Practice Address - Phone:505-768-5450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2018-0083363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant