Healthcare Provider Details

I. General information

NPI: 1063465318
Provider Name (Legal Business Name): MITCHELL KIRK BOGLE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 W BROWN RD SUITE 4001
MESA AZ
85201-3221
US

IV. Provider business mailing address

101 E REDLANDS BLVD SUITE 212
REDLANDS CA
92373-4775
US

V. Phone/Fax

Practice location:
  • Phone: 480-962-4269
  • Fax: 480-962-3702
Mailing address:
  • Phone: 909-335-8649
  • Fax: 909-335-1994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3411
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: