Provider Demographics
NPI:1528600384
Name:MENDIETA, BERTHA P (PA)
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:P
Last Name:MENDIETA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-5749
Mailing Address - Country:US
Mailing Address - Phone:361-575-6396
Mailing Address - Fax:361-578-5203
Practice Address - Street 1:2701 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-5749
Practice Address - Country:US
Practice Address - Phone:361-575-6396
Practice Address - Fax:361-578-5203
Is Sole Proprietor?:No
Enumeration Date:2019-10-14
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1014596363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant