Basic Information
| Provider Information | |||||||||
| NPI: | 1992013445 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDEZ | ||||||||
| FirstName: | MARISA | ||||||||
| MiddleName: | KOLTA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOLTA | ||||||||
| OtherFirstName: | MARISA | ||||||||
| OtherMiddleName: | RUTH | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS, PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12401 WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906021006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5627895401 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12401 WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906021006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5627895401 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2010 | ||||||||
| LastUpdateDate: | 09/17/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA19123 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.