Basic Information
| Provider Information | |||||||||
| NPI: | 1962471078 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | MANUEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 FLYNN RD | ||||||||
| Address2: | |||||||||
| City: | CAMARILLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930125092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056733930 | ||||||||
| FaxNumber: | 8056593217 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | FILLMORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930151920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055244926 | ||||||||
| FaxNumber: | 8055244137 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 12/16/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 11411 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.