Provider Demographics
NPI:1720648728
Name:MESA, BREANNA DOMINIQUE (PA-C)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:DOMINIQUE
Last Name:MESA
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 1:72 ALLEN DR
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-3371
Mailing Address - Country:US
Mailing Address - Phone:973-934-8686
Mailing Address - Fax:
Practice Address - Street 1:127 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-3616
Practice Address - Country:US
Practice Address - Phone:201-431-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
NJ25MP00527800363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical