Provider Demographics
NPI:1235892233
Name:MENDOZA, TANIA
Entity Type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:MENDOZA
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 1:2406 NW JACKSON AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-5389
Mailing Address - Country:US
Mailing Address - Phone:541-571-8736
Mailing Address - Fax:
Practice Address - Street 1:530 NW 27TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-5298
Practice Address - Country:US
Practice Address - Phone:541-766-6835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-16
Last Update Date:2021-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORIHNOtherINTERCOMMUNITY HEALTH PLAN