Provider Demographics
NPI:1174412910
Name:MENDOZA, ALISA JOSEFINA (PA)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:JOSEFINA
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12226 PASCAL AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5426
Mailing Address - Country:US
Mailing Address - Phone:951-315-1129
Mailing Address - Fax:
Practice Address - Street 1:2101 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4836
Practice Address - Country:US
Practice Address - Phone:909-883-8711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-28
Last Update Date:2025-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant