Provider Demographics
NPI:1194380253
Name:MERCADO, EDGAR IVAN
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:IVAN
Last Name:MERCADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 O ST STE 202
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1828
Mailing Address - Country:US
Mailing Address - Phone:559-369-4625
Mailing Address - Fax:
Practice Address - Street 1:1350 O ST STE 202
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1828
Practice Address - Country:US
Practice Address - Phone:559-369-4625
Practice Address - Fax:559-369-7259
Is Sole Proprietor?:No
Enumeration Date:2019-05-04
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant