Provider Demographics
NPI:1174649933
Name:MENDOZA, KIMBERLY LYNN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LYNN
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 GOSSAMER LN UNIT 7
Mailing Address - Street 2:
Mailing Address - City:INLET BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32461-7051
Mailing Address - Country:US
Mailing Address - Phone:703-964-7838
Mailing Address - Fax:
Practice Address - Street 1:2011 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4545
Practice Address - Country:US
Practice Address - Phone:850-691-4188
Practice Address - Fax:833-687-1451
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114084363A00000X
FL23539225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005835C38Medicare ID - Type Unspecified
VAQ29199Medicare UPIN