Healthcare Provider Details

I. General information

NPI: 1699399634
Provider Name (Legal Business Name): ANGELICA MENDOZA MEDICAL ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2020
Last Update Date: 06/05/2020
Certification Date: 06/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1628 BROADWAY ST
VALLEJO CA
94590-2405
US

IV. Provider business mailing address

1628 BROADWAY ST
VALLEJO CA
94590-2405
US

V. Phone/Fax

Practice location:
  • Phone: 707-649-8300
  • Fax: 707-649-8302
Mailing address:
  • Phone: 707-649-8300
  • Fax: 707-649-8302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License NumberB4K5W6G8
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: