Provider Demographics
NPI:1144507237
Name:MENDES, VICENTE GABRIEL MONTEIRO (PA-C)
Entity type:Individual
Prefix:
First Name:VICENTE
Middle Name:GABRIEL MONTEIRO
Last Name:MENDES
Suffix:
Gender:M
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 788250
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92278-8250
Mailing Address - Country:US
Mailing Address - Phone:760-917-3879
Mailing Address - Fax:
Practice Address - Street 1:34101 FARENHOLT AVE
Practice Address - Street 2:BUILDING 14
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-7000
Practice Address - Country:US
Practice Address - Phone:619-532-5544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-03
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X, 1710I1002X
CAPA57011363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Single Specialty
No1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman