Provider Demographics
NPI:1992013445
Name:MENDEZ, MARISA KOLTA (MS, PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:KOLTA
Last Name:MENDEZ
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:MS
Other - First Name:MARISA
Other - Middle Name:RUTH
Other - Last Name:KOLTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, PA-C
Mailing Address - Street 1:12401 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90602-1006
Mailing Address - Country:US
Mailing Address - Phone:562-789-5401
Mailing Address - Fax:
Practice Address - Street 1:12401 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1006
Practice Address - Country:US
Practice Address - Phone:562-789-5401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19123363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant