Healthcare Provider Details

I. General information

NPI: 1689100802
Provider Name (Legal Business Name): MAURICIO MEJIA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2017
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 6TH ST
MODESTO CA
95354-2203
US

IV. Provider business mailing address

1114 6TH ST
MODESTO CA
95354-2203
US

V. Phone/Fax

Practice location:
  • Phone: 209-722-4842
  • Fax:
Mailing address:
  • Phone: 209-576-2845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 9109507
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA65281
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: