=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104976059
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MANUEL EDWARD MEJIAS JR. PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 N FRESNO ST
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93703-3845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-295-6700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3705 N ELLENDALE AVE
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93722-1154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-274-1120
-----------------------------------------------------
Fax | 559-274-1120
-----------------------------------------------------
=====================================================
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 | PA12717
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------