Provider Demographics
NPI:1144495128
Name:MEZA, RICHARD JUN
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:JUN
Last Name:MEZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:
Other - Last Name:MEZA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:3339 WILLOWBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-1707
Mailing Address - Country:US
Mailing Address - Phone:209-957-5214
Mailing Address - Fax:
Practice Address - Street 1:1325 COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-5131
Practice Address - Country:US
Practice Address - Phone:530-662-3961
Practice Address - Fax:530-668-9429
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 17656363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner