Provider Demographics
NPI:1124492814
Name:MCTAGUE, VANESSA H
Entity type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:H
Last Name:MCTAGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:
Other - Last Name:HERNANDEZ MEZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:398 HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3537
Mailing Address - Country:US
Mailing Address - Phone:907-374-4911
Mailing Address - Fax:
Practice Address - Street 1:398 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3537
Practice Address - Country:US
Practice Address - Phone:907-374-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK103781225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant