1316196322 NPI number — MRS. RACHEL MARIE MENDOZA PA-C

Table of content: MRS. RACHEL MARIE MENDOZA PA-C (NPI 1316196322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316196322 NPI number — MRS. RACHEL MARIE MENDOZA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENDOZA
Provider First Name:
RACHEL
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CRAIG
Provider Other First Name:
RACHEL
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316196322
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
217 W CENTRAL AVE STE G
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOMPOC
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93436-2830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-735-4292
Provider Business Mailing Address Fax Number:
805-735-4293

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
217 W CENTRAL AVE STE G
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOMPOC
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93436-2830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-735-4292
Provider Business Practice Location Address Fax Number:
805-735-4293
Provider Enumeration Date:
09/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA19915 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1084058 . This is a "THE NATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 19915 . This is a "CALIFORNIA STATE PHYSICIAN ASSISTANT LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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