Basic Information
| Provider Information | |||||||||
| NPI: | 1710445945 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEZA | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | MARGARITA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | STUDENT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MEZA | ||||||||
| OtherFirstName: | WENDY | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | STUDENT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11632 130TH ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH OZONE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114202604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9179810276 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2857 LINDEN BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112085126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182353100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2019 | ||||||||
| LastUpdateDate: | 03/06/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1000X | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
No ID Information.