Basic Information
| Provider Information | |||||||||
| NPI: | 1194786186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | MARY BETH | ||||||||
| MiddleName: | LENNOX | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROGALSKI OR LENNOX | ||||||||
| OtherFirstName: | MARY BETH | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 25 CROSSROADS DR STE 306 | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211175437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4437382872 | ||||||||
| FaxNumber: | 4437382713 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 MALCOLM DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | WESTMINSTER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211576160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108761633 | ||||||||
| FaxNumber: | 4108402100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 04/29/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | C01911 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | P00250839 | 01 | MD | R/R MEDICARE PROVIDER # | OTHER | 970005976 | 01 | MD | R/R MEDICARE PROVIDER # | OTHER | CN6601 | 01 | MD | R/R MEDICARE GROUP # | OTHER |