=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407549660
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAIGE MCKENNA MOHL OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2023
-----------------------------------------------------
Last Update Date | 04/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13340 N 94TH DR
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85381-4236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-977-8341
-----------------------------------------------------
Fax | 623-933-2952
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23555 N DESERT PEAK PKWY APT 715
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85024-6314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-887-9414
-----------------------------------------------------
Fax | 623-933-2962
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT-002702
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------