Provider Demographics
NPI:1790873727
Name:MARESCA, ADRIENNE L (PA-C)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:L
Last Name:MARESCA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ADRIENNE
Other - Middle Name:L
Other - Last Name:GORAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:P O BOX 107
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-0107
Mailing Address - Country:US
Mailing Address - Phone:231-947-0673
Mailing Address - Fax:801-740-2847
Practice Address - Street 1:1105 6TH STREET
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-947-0673
Practice Address - Fax:801-740-2847
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004855363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical