Provider Demographics
NPI:1629005111
Name:MESACK, RENEE DEANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:DEANNE
Last Name:MESACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 N CENTER AVE
Mailing Address - Street 2:SUITE 298
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1595
Mailing Address - Country:US
Mailing Address - Phone:989-731-7708
Mailing Address - Fax:989-731-7929
Practice Address - Street 1:1996 WALDEN DR
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-8241
Practice Address - Country:US
Practice Address - Phone:989-731-4111
Practice Address - Fax:989-705-8511
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002853363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
381303843OtherTAX ID
OF96004OtherMEDICARE GROUP NUMBER
OF96004OtherMEDICARE GROUP NUMBER
381303843OtherTAX ID