Provider Demographics
NPI:1053133637
Name:MEJIA DE ORTIZ, BLANCA P (PA)
Entity type:Individual
Prefix:
First Name:BLANCA
Middle Name:P
Last Name:MEJIA DE ORTIZ
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 1:11621 W RIO VISTA LN
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-7618
Mailing Address - Country:US
Mailing Address - Phone:623-455-0992
Mailing Address - Fax:
Practice Address - Street 1:11621 W RIO VISTA LN
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-7618
Practice Address - Country:US
Practice Address - Phone:623-455-0992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2120363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant