Healthcare Provider Details

I. General information

NPI: 1962970343
Provider Name (Legal Business Name): HALEY LAENE BOHL MEJIAS MMS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2018
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2721 S SAN TAN VILLAGE PKWY STE 104
GILBERT AZ
85295-0713
US

IV. Provider business mailing address

2721 S SAN TAN VILLAGE PKWY
GILBERT AZ
85295-0713
US

V. Phone/Fax

Practice location:
  • Phone: 480-837-4300
  • Fax:
Mailing address:
  • Phone: 480-837-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7305
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: