Provider Demographics
NPI:1366011090
Name:MOYA-MENDEZ, MEREDITH
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:MOYA-MENDEZ
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-2060
Mailing Address - Fax:239-424-2061
Practice Address - Street 1:650 DEL PRADO BLVD S STE 100
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-5617
Practice Address - Country:US
Practice Address - Phone:239-424-2060
Practice Address - Fax:239-424-2061
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-17
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114178000Medicaid