Provider Demographics
NPI:1689100802
Name:MEJIA, MAURICIO (PA)
Entity type:Individual
Prefix:
First Name:MAURICIO
Middle Name:
Last Name:MEJIA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-2203
Mailing Address - Country:US
Mailing Address - Phone:209-576-2845
Mailing Address - Fax:
Practice Address - Street 1:1114 6TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-2203
Practice Address - Country:US
Practice Address - Phone:209-722-4842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-08
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9109507363A00000X
CAPA65281363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant