=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144491259
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVERARDO MEJIA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2008
-----------------------------------------------------
Last Update Date | 12/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11725 GARVEY AVE STE 5B
-----------------------------------------------------
City | EL MONTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91732-4534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-579-0707
-----------------------------------------------------
Fax | 626-579-0235
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11725 GARVEY AVE STE 5B
-----------------------------------------------------
City | EL MONTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91732-4534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-579-0707
-----------------------------------------------------
Fax | 626-579-0235
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA19593
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------