Provider Demographics
NPI:1689820037
Name:HATZIDAKIS, MONDANA (PA-C)
Entity Type:Individual
Prefix:
First Name:MONDANA
Middle Name:
Last Name:HATZIDAKIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7601 IMPERIAL HWY STE JPI 3120
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242-3456
Mailing Address - Country:US
Mailing Address - Phone:562-385-7611
Mailing Address - Fax:
Practice Address - Street 1:7601 IMPERIAL HWY STE JPI 3120
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242
Practice Address - Country:US
Practice Address - Phone:562-385-7611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-15
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19799363A00000X
TXPA06012363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant