Provider Demographics
NPI:1366817272
Name:MENDOZA, MARA ANDREA SUZARA
Entity Type:Individual
Prefix:
First Name:MARA ANDREA
Middle Name:SUZARA
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 1:11962 DONNA LN
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-2514
Mailing Address - Country:US
Mailing Address - Phone:714-350-4531
Mailing Address - Fax:
Practice Address - Street 1:11962 DONNA LN
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-2514
Practice Address - Country:US
Practice Address - Phone:714-350-4531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10399225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant