Provider Demographics
NPI:1467812800
Name:MORTA, MITCHELL
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:MORTA
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 1:122 E SAN ANTONIO DR
Mailing Address - Street 2:
Mailing Address - City:KING CITY
Mailing Address - State:CA
Mailing Address - Zip Code:93930-2518
Mailing Address - Country:US
Mailing Address - Phone:831-385-5944
Mailing Address - Fax:831-385-8618
Practice Address - Street 1:122 E SAN ANTONIO DR
Practice Address - Street 2:
Practice Address - City:KING CITY
Practice Address - State:CA
Practice Address - Zip Code:93930-2518
Practice Address - Country:US
Practice Address - Phone:831-385-5944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-27
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60898385363LF0000X
CA95003915363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily