Healthcare Provider Details

I. General information

NPI: 1518429661
Provider Name (Legal Business Name): MARIAH CHOLLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9059 W. LAKE PLEASANT PKWY STE E-540
PEORIA AZ
85382
US

IV. Provider business mailing address

9059 W. LAKE PLEASANT PKWY STE E-540
PEORIA AZ
85382
US

V. Phone/Fax

Practice location:
  • Phone: 623-322-3380
  • Fax: 623-322-4399
Mailing address:
  • Phone: 623-322-3380
  • Fax: 623-322-4399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: