Provider Demographics
NPI:1679349377
Name:MESA, MIGUEL ANGEL
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANGEL
Last Name:MESA
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 1:11390 N 24TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTAGUE
Mailing Address - State:MI
Mailing Address - Zip Code:49437-9534
Mailing Address - Country:US
Mailing Address - Phone:616-238-6951
Mailing Address - Fax:
Practice Address - Street 1:1675 LEAHY ST STE 210B
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5542
Practice Address - Country:US
Practice Address - Phone:231-672-3201
Practice Address - Fax:231-672-8404
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker