Provider Demographics
NPI:1659303881
Name:FURTEK, MARYANNE MENDOZA (PA)
Entity Type:Individual
Prefix:
First Name:MARYANNE
Middle Name:MENDOZA
Last Name:FURTEK
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:PO BOX 690
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90801-0690
Mailing Address - Country:US
Mailing Address - Phone:562-809-3547
Mailing Address - Fax:
Practice Address - Street 1:1100 WEST STEWART DRIVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3849
Practice Address - Country:US
Practice Address - Phone:714-633-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13534363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13534Medicaid
CAWPA13534AMedicare ID - Type Unspecified
CAPA13534Medicaid