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General NPI Number Information
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NPI Number | 1174378673
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Entity Type | Individual
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Provider Name | MIREILLE JOSEPH JEROME MD- PA
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Gender | Female
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Dates
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Enumeration Date | 04/19/2024
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Last Update Date | 09/29/2024
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Provider Practice Location Address
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Address Line | 6859 E REMBRANDT AVE STE 117
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City | MESA
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State | AZ
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Zip | 85212-3630
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Country | US
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Telephone | 754-422-5700
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Fax |
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Provider Business Mailing Address
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Address Line | 6859 E REMBRANDT AVE STE 117
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City | MESA
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State | AZ
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Zip | 85212-3630
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Country | US
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Telephone | 754-422-5700
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 1780
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License Number State | PR
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 10398
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License Number State | AZ
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