Provider Demographics
NPI:1194786186
Name:MENDOZA, MARY BETH LENNOX (PA-C)
Entity type:Individual
Prefix:MS
First Name:MARY BETH
Middle Name:LENNOX
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MARY BETH
Other - Middle Name:
Other - Last Name:ROGALSKI OR LENNOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:25 CROSSROADS DR STE 306
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5437
Mailing Address - Country:US
Mailing Address - Phone:443-738-2872
Mailing Address - Fax:443-738-2713
Practice Address - Street 1:410 MALCOLM DR
Practice Address - Street 2:SUITE A
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-6160
Practice Address - Country:US
Practice Address - Phone:410-876-1633
Practice Address - Fax:410-840-2100
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC01911363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00250839OtherR/R MEDICARE PROVIDER #
MD970005976OtherR/R MEDICARE PROVIDER #
MDCN6601OtherR/R MEDICARE GROUP #
MDCN6601OtherR/R MEDICARE GROUP #
MD970005976OtherR/R MEDICARE PROVIDER #
MDKL33E895Medicare PIN