=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063465318
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MITCHELL KIRK BOGLE P.A.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2006
-----------------------------------------------------
Last Update Date | 04/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 560 W BROWN RD SUITE 4001
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85201-3221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-962-4269
-----------------------------------------------------
Fax | 480-962-3702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 E REDLANDS BLVD SUITE 212
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92373-4775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-335-8649
-----------------------------------------------------
Fax | 909-335-1994
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 3411
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------