Basic Information
| Provider Information | |||||||||
| NPI: | 1518429661 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHOLLEY | ||||||||
| FirstName: | MARIAH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9059 W. LAKE PLEASANT PKWY | ||||||||
| Address2: | STE E-540 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233223380 | ||||||||
| FaxNumber: | 6233224399 | ||||||||
| Practice Location | |||||||||
| Address1: | 9059 W. LAKE PLEASANT PKWY | ||||||||
| Address2: | STE E-540 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233223380 | ||||||||
| FaxNumber: | 6233224399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2019 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 320080797 | 01 | AZ | SURPRISE PEDIATRICS | OTHER |