Provider Demographics
NPI:1457922783
Name:MOJICA, PETRA ROSA
Entity type:Individual
Prefix:
First Name:PETRA
Middle Name:ROSA
Last Name:MOJICA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N MALACATE ST
Mailing Address - Street 2:
Mailing Address - City:AJO
Mailing Address - State:AZ
Mailing Address - Zip Code:85321-2254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:520-387-6036
Practice Address - Street 1:14574 S SUNLAND GIN RD
Practice Address - Street 2:
Practice Address - City:ARIZONA CITY
Practice Address - State:AZ
Practice Address - Zip Code:85123
Practice Address - Country:US
Practice Address - Phone:520-387-5651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-07
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ280587363LF0000X
AZF06211981363LF0000X
TXF0621181363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily