Provider Demographics
NPI:1417615303
Name:MEJIA, AUTUMN SKYE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:SKYE
Last Name:MEJIA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:AUTUMN
Other - Middle Name:SKYE
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:719 N 25TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223
Mailing Address - Country:US
Mailing Address - Phone:804-780-0840
Mailing Address - Fax:
Practice Address - Street 1:719 N 25TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-6539
Practice Address - Country:US
Practice Address - Phone:804-780-0840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0000008202363A00000X
VA0110008202363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant