Provider Demographics
NPI:1669403150
Name:MENDOZA, ROBERTO ARTURO (PA)
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:ARTURO
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 W LOMA ALTA DR
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-3931
Mailing Address - Country:US
Mailing Address - Phone:626-797-1689
Mailing Address - Fax:
Practice Address - Street 1:9449 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-2814
Practice Address - Country:US
Practice Address - Phone:562-657-2652
Practice Address - Fax:562-657-2846
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15542363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE90066Medicare UPIN