Provider Demographics
NPI:1528439767
Name:MONDRAGON, LINDA (PA-C)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:MONDRAGON
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 80690
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-0690
Mailing Address - Country:US
Mailing Address - Phone:330-363-7444
Mailing Address - Fax:330-363-7770
Practice Address - Street 1:340 OXFORD ST STE 120
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-1969
Practice Address - Country:US
Practice Address - Phone:234-801-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.009174RX363A00000X
FLPA9109083363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022307900Medicaid