Provider Demographics
NPI:1780680405
Name:MENDENHALL, MARCIA ANN (PA)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:ANN
Last Name:MENDENHALL
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 62
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-0062
Mailing Address - Country:US
Mailing Address - Phone:970-244-6100
Mailing Address - Fax:970-255-1809
Practice Address - Street 1:1100 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-8219
Practice Address - Country:US
Practice Address - Phone:970-244-6100
Practice Address - Fax:970-255-1809
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2007-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1713363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO39583244Medicaid
COC535818Medicare PIN
CO39583244Medicaid