Provider Demographics
NPI:1063465318
Name:BOGLE, MITCHELL KIRK (PA)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:KIRK
Last Name:BOGLE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:101 E REDLANDS BLVD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4775
Mailing Address - Country:US
Mailing Address - Phone:909-335-8649
Mailing Address - Fax:909-335-1994
Practice Address - Street 1:560 W BROWN RD
Practice Address - Street 2:SUITE 4001
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3221
Practice Address - Country:US
Practice Address - Phone:480-962-4269
Practice Address - Fax:480-962-3702
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-04-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ3411363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ109524Medicare PIN
AZ120639Medicare PIN