Provider Demographics
NPI:1952967697
Name:MENDOZA, LAIDELYN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:LAIDELYN
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12921 NW 9TH LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33182-2391
Mailing Address - Country:US
Mailing Address - Phone:786-306-2858
Mailing Address - Fax:
Practice Address - Street 1:8950 N KENDALL DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2144
Practice Address - Country:US
Practice Address - Phone:305-274-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112008363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant