=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225466915
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA MARCELA MEJIA PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2013
-----------------------------------------------------
Last Update Date | 02/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5755 CEDAR LN STE 134 HOWARD COUNTY GENERAL HOSPITAL
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21044-2912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-884-4746
-----------------------------------------------------
Fax | 410-884-4749
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2122 TUCSON AVE UNIT D
-----------------------------------------------------
City | ANDREWS AIR FORCE BASE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20762-5566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-902-4080
-----------------------------------------------------
Fax | 240-348-4531
-----------------------------------------------------
=====================================================
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 | 017118
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------