Provider Demographics
NPI:1689100802
Name:MEJIA, MAURICIO (PA)
Entity Type:Individual
Prefix:
First Name:MAURICIO
Middle Name:
Last Name:MEJIA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 E CR 466
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159
Mailing Address - Country:US
Mailing Address - Phone:352-674-9218
Mailing Address - Fax:
Practice Address - Street 1:805 E CR 466
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159
Practice Address - Country:US
Practice Address - Phone:352-674-9218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-08
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9109507363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant