Provider Demographics
NPI:1962146498
Name:MENDOZA, MONICA JAZMINE
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:JAZMINE
Last Name:MENDOZA
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 1:380 CHASE AVE
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2924
Mailing Address - Country:US
Mailing Address - Phone:509-897-5836
Mailing Address - Fax:509-897-5743
Practice Address - Street 1:380 CHASE AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2924
Practice Address - Country:US
Practice Address - Phone:509-897-5836
Practice Address - Fax:509-897-5743
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61302924363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant