Healthcare Provider Details

I. General information

NPI: 1255950127
Provider Name (Legal Business Name): MARK DANIEL CAGLE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5140 E THOMAS RD
PHOENIX AZ
85018-7915
US

IV. Provider business mailing address

1847 W HEATHERBRAE DR
PHOENIX AZ
85015-4764
US

V. Phone/Fax

Practice location:
  • Phone: 602-207-8400
  • Fax: 602-535-3166
Mailing address:
  • Phone: 602-274-2100
  • Fax: 602-535-3166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8078
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number8078
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: