Healthcare Provider Details

I. General information

NPI: 1477082063
Provider Name (Legal Business Name): MICKENSI PAGET PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 06/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8410 W THOMAS RD STE 134
PHOENIX AZ
85037-3374
US

IV. Provider business mailing address

PO BOX 6730
CHANDLER AZ
85246-6730
US

V. Phone/Fax

Practice location:
  • Phone: 623-907-2377
  • Fax: 480-857-2667
Mailing address:
  • Phone: 480-821-3600
  • Fax:

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: