Provider Demographics
NPI:1437344264
Name:NEELY, MICOLE D (PA-C)
Entity Type:Individual
Prefix:
First Name:MICOLE
Middle Name:D
Last Name:NEELY
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:PO BOX 65223
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85082-5223
Mailing Address - Country:US
Mailing Address - Phone:602-689-2349
Mailing Address - Fax:
Practice Address - Street 1:702 W CAMELBACK RD STE 20
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-2291
Practice Address - Country:US
Practice Address - Phone:602-845-5950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3679363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ409214Medicaid
AZ3679OtherAZ LICENSE
AZ409214Medicaid