Provider Demographics
NPI:1821632308
Name:MENDOZA, JUAN MIGUEL FERNANDEZ (PT)
Entity Type:Individual
Prefix:
First Name:JUAN MIGUEL
Middle Name:FERNANDEZ
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 S 9TH ST
Mailing Address - Street 2:STE 4
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-2631
Mailing Address - Country:US
Mailing Address - Phone:765-524-3946
Mailing Address - Fax:317-708-6496
Practice Address - Street 1:800 MEDCALF ST
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563
Practice Address - Country:US
Practice Address - Phone:360-249-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60998517225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist