Provider Demographics
NPI:1386617439
Name:MENDEZ-RUNGE, ENITH (PA)
Entity type:Individual
Prefix:MS
First Name:ENITH
Middle Name:
Last Name:MENDEZ-RUNGE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ENITH
Other - Middle Name:
Other - Last Name:MENDEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 391
Mailing Address - Street 2:
Mailing Address - City:WILBRAHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01095-0391
Mailing Address - Country:US
Mailing Address - Phone:508-595-0531
Mailing Address - Fax:508-829-5367
Practice Address - Street 1:189 MAY STREET
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01602
Practice Address - Country:US
Practice Address - Phone:508-791-6351
Practice Address - Fax:508-753-2087
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1841363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q28827Medicare UPIN
MAAP2287Medicare ID - Type Unspecified