Provider Demographics
NPI:1114692902
Name:MORDARSKA, MALGORZATA
Entity Type:Individual
Prefix:
First Name:MALGORZATA
Middle Name:
Last Name:MORDARSKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 KENOSHA ST APT B
Mailing Address - Street 2:
Mailing Address - City:WALWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:53184-9660
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5125 SKYWAY
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-5624
Practice Address - Country:US
Practice Address - Phone:530-872-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62733363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant