Healthcare Provider Details

I. General information

NPI: 1720209661
Provider Name (Legal Business Name): MICHAEL FORNOLES MENDOZA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 11/30/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15031 RINALDI ST
MISSION HILLS CA
91345-1207
US

IV. Provider business mailing address

20811 TULSA ST
CHATSWORTH CA
91311-1535
US

V. Phone/Fax

Practice location:
  • Phone: 818-365-8051
  • Fax:
Mailing address:
  • Phone: 818-427-2141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18750
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: