Provider Demographics
NPI:1710543194
Name:MENDOZA, TIFFANY DARLENE (PA-C)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DARLENE
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:PA-C
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 857
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-0857
Mailing Address - Country:US
Mailing Address - Phone:209-202-8388
Mailing Address - Fax:
Practice Address - Street 1:93 KANSAS ST APT 605
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-1476
Practice Address - Country:US
Practice Address - Phone:209-202-8388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-11
Last Update Date:2019-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant