MEDICARE: MITCHELL KIRK BOGLE P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	3411	AZ

General Provider Information

NPI Number	:	1063465318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITCHELL KIRK BOGLE P.A.

Provider Business Mailing Address
First Line	:	101 E REDLANDS BLVD
Second Line	:	SUITE 212
City	:	REDLANDS
State	:	CA
Zip	:	92373-4775
Country	:	US
Telephone Number	:	909-335-8649
Fax Number	:	909-335-1994

Provider Business Practice Location Address
First Line	:	560 W BROWN RD
Second Line	:	SUITE 4001
City	:	MESA
State	:	AZ
Zip	:	85201-3221
Country	:	US
Telephone Number	:	480-962-4269
Fax Number	:	480-962-3702

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	04/01/2008

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