Provider Demographics
NPI:1356080527
Name:WATANABE, MIKA (PA-C)
Entity Type:Individual
Prefix:
First Name:MIKA
Middle Name:
Last Name:WATANABE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14044 W CAMELBACK RD STE 118
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-9481
Mailing Address - Country:US
Mailing Address - Phone:623-547-2600
Mailing Address - Fax:623-547-1899
Practice Address - Street 1:14044 W CAMELBACK RD STE 118
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-9481
Practice Address - Country:US
Practice Address - Phone:623-547-2600
Practice Address - Fax:623-547-1899
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9294363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty