Provider Demographics
NPI:1639708373
Name:BRANCHELOR, MESADIEU
Entity type:Individual
Prefix:
First Name:MESADIEU
Middle Name:
Last Name:BRANCHELOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 S HUNT CLUB BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-2428
Mailing Address - Country:US
Mailing Address - Phone:407-304-9337
Mailing Address - Fax:
Practice Address - Street 1:425 S HUNT CLUB BLVD STE 201
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-2428
Practice Address - Country:US
Practice Address - Phone:407-304-9337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-04
Last Update Date:2020-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR000390-P.A.363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant