Basic Information
| Provider Information | |||||||||
| NPI: | 1629005111 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MESACK | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | DEANNE | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 829 N CENTER AVE | ||||||||
| Address2: | SUITE 298 | ||||||||
| City: | GAYLORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497351595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897317708 | ||||||||
| FaxNumber: | 9897317929 | ||||||||
| Practice Location | |||||||||
| Address1: | 1996 WALDEN DR | ||||||||
| Address2: | |||||||||
| City: | GAYLORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497358241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897314111 | ||||||||
| FaxNumber: | 9897058511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 12/03/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601002853 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 381303843 | 01 | TAX ID | OTHER | OF96004 | 01 | MEDICARE GROUP NUMBER | OTHER |