Provider Demographics
NPI:1366168841
Name:MUJICA RENDON, OCTAVIO M
Entity type:Individual
Prefix:
First Name:OCTAVIO
Middle Name:M
Last Name:MUJICA RENDON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:OCTAVIO
Other - Middle Name:MIGUEL
Other - Last Name:MUJICA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:3140 N 35TH AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-5270
Mailing Address - Country:US
Mailing Address - Phone:602-353-6656
Mailing Address - Fax:
Practice Address - Street 1:3140 N 35TH AVE STE 7
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-5270
Practice Address - Country:US
Practice Address - Phone:602-353-6656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty