Provider Demographics
NPI:1376887976
Name:MESDAQ, MENA (PA)
Entity Type:Individual
Prefix:
First Name:MENA
Middle Name:
Last Name:MESDAQ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 ROSEBAY DR
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-3323
Mailing Address - Country:US
Mailing Address - Phone:760-807-3583
Mailing Address - Fax:
Practice Address - Street 1:6515 LA JOLLA BLVD
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-6066
Practice Address - Country:US
Practice Address - Phone:858-454-7157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22646363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical