Healthcare Provider Details

I. General information

NPI: 1104976059
Provider Name (Legal Business Name): MANUEL EDWARD MEJIAS JR. PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N FRESNO ST
FRESNO CA
93703-3845
US

IV. Provider business mailing address

3705 N ELLENDALE AVE
FRESNO CA
93722-1154
US

V. Phone/Fax

Practice location:
  • Phone: 559-295-6700
  • Fax:
Mailing address:
  • Phone: 559-274-1120
  • Fax: 559-274-1120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA12717
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: