Provider Demographics
NPI:1902298987
Name:MENDOZA MORENO, SIMON (PA-C)
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:MENDOZA MORENO
Suffix:
Gender:M
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 1:600 ORONDO AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2800
Mailing Address - Country:US
Mailing Address - Phone:509-662-6000
Mailing Address - Fax:509-664-4590
Practice Address - Street 1:6240 TACOMA MALL BLVD STE 101
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-6819
Practice Address - Country:US
Practice Address - Phone:253-271-9720
Practice Address - Fax:253-212-3372
Is Sole Proprietor?:No
Enumeration Date:2015-02-27
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60672657363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical