Provider Demographics
NPI:1144208471
Name:MARES FERNANDEZ, ROSALEE M (PAC)
Entity Type:Individual
Prefix:
First Name:ROSALEE
Middle Name:M
Last Name:MARES FERNANDEZ
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4631 MERLE HAY RD
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50322-1962
Mailing Address - Country:US
Mailing Address - Phone:515-278-0949
Mailing Address - Fax:515-278-6721
Practice Address - Street 1:4631 MERLE HAY RD
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50322-1962
Practice Address - Country:US
Practice Address - Phone:515-278-0949
Practice Address - Fax:515-278-6721
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000990363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA45621Medicare ID - Type Unspecified
IAR29944Medicare UPIN