Provider Demographics
NPI:1225786239
Name:MENDIETA, MARIELA CARLA (PA)
Entity Type:Individual
Prefix:
First Name:MARIELA
Middle Name:CARLA
Last Name:MENDIETA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12110 RED QUILL LN APT 1218
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-3572
Mailing Address - Country:US
Mailing Address - Phone:786-422-3026
Mailing Address - Fax:
Practice Address - Street 1:3775 N LECANTO HWY
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:FL
Practice Address - Zip Code:34465-3559
Practice Address - Country:US
Practice Address - Phone:352-746-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE