Healthcare Provider Details

I. General information

NPI: 1932683778
Provider Name (Legal Business Name): MARK MENDOZA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 S KING ST
HONOLULU HI
96813-3097
US

IV. Provider business mailing address

95-1047 HAKALA ST
MILILANI HI
96789-4256
US

V. Phone/Fax

Practice location:
  • Phone: 808-522-4344
  • Fax:
Mailing address:
  • Phone: 808-382-4364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2393
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: