Healthcare Provider Details

I. General information

NPI: 1417386475
Provider Name (Legal Business Name): DAVID MENDONSA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2013
Last Update Date: 03/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15-1697 TENTH AVE
KEAAU HI
96749
US

IV. Provider business mailing address

PO BOX 5484
HILO HI
96720-8484
US

V. Phone/Fax

Practice location:
  • Phone: 808-377-4734
  • Fax:
Mailing address:
  • Phone: 808-377-4734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberATP1392
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberAMD621
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: