MEDICARE: MICKENSI PAGET PHYSICIAN ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1477082063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICKENSI PAGET PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	PO BOX 6730
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85246-6730
Country	:	US
Telephone Number	:	480-821-3600
Fax Number	:

Provider Business Practice Location Address
First Line	:	8410 W THOMAS RD STE 134
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85037-3374
Country	:	US
Telephone Number	:	623-907-2377
Fax Number	:	480-857-2667

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2017
Last Update Date	:	06/07/2017

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