Provider Demographics
NPI:1336645928
Name:MENDOZA, THEODORE BULACAN III (FNP-BC)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:BULACAN
Last Name:MENDOZA
Suffix:III
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7328 LAGUNA
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-0139
Mailing Address - Country:US
Mailing Address - Phone:972-898-8933
Mailing Address - Fax:
Practice Address - Street 1:6407 S COOPER ST STE 117
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76001-5813
Practice Address - Country:US
Practice Address - Phone:817-472-7601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136094363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily