Basic Information
| Provider Information | |||||||||
| NPI: | 1275724114 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEJIA | ||||||||
| FirstName: | CARLEY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BARTOLOME | ||||||||
| OtherFirstName: | CARLEY | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9 HEALTHCARE DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BIDDEFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040059449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072829080 | ||||||||
| FaxNumber: | 2072829180 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 SHAPE DR | ||||||||
| Address2: | |||||||||
| City: | KENNEBUNK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040436601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074678930 | ||||||||
| FaxNumber: | 2074678969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2007 | ||||||||
| LastUpdateDate: | 01/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA001103 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 432995099 | 05 | ME | MEDICAID |