Provider Demographics
NPI:1174792287
Name:MEJIA, MANUEL FELIX JR (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:FELIX
Last Name:MEJIA
Suffix:JR
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7559 W SAN JUAN AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85303-5121
Mailing Address - Country:US
Mailing Address - Phone:602-406-4765
Mailing Address - Fax:
Practice Address - Street 1:350 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4409
Practice Address - Country:US
Practice Address - Phone:602-406-4765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-22
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2727363LF0000X
AZAP4337363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ122035Medicare UPIN