Healthcare Provider Details

I. General information

NPI: 1144491259
Provider Name (Legal Business Name): EVERARDO MEJIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 12/02/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11725 GARVEY AVE STE 5B
EL MONTE CA
91732-4534
US

IV. Provider business mailing address

11725 GARVEY AVE STE 5B
EL MONTE CA
91732-4534
US

V. Phone/Fax

Practice location:
  • Phone: 626-579-0707
  • Fax: 626-579-0235
Mailing address:
  • Phone: 626-579-0707
  • Fax: 626-579-0235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19593
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: