Basic Information
| Provider Information | |||||||||
| NPI: | 1982227062 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | JAIRO | ||||||||
| MiddleName: | ENRIGUE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 LILLY RD NE | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3064937230 | ||||||||
| FaxNumber: | 3604934180 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 LILLY RD NE | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3064937230 | ||||||||
| FaxNumber: | 3604934180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2020 | ||||||||
| LastUpdateDate: | 10/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.