Provider Demographics
NPI:1194765149
Name:MENDENHALL, JAMES DOUGLASS (FNP)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:DOUGLASS
Last Name:MENDENHALL
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10333 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-5808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10333 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-5808
Practice Address - Country:US
Practice Address - Phone:805-468-2188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320702363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANPF2815OtherNP-F LICENSE
E58439Medicare UPIN