Provider Demographics
NPI:1427124163
Name:MEZONA ORTHOPAEDIC PA
Entity type:Organization
Organization Name:MEZONA ORTHOPAEDIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PROCKNOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-964-2908
Mailing Address - Street 1:2940 E BANNER GATEWAY DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2168
Mailing Address - Country:US
Mailing Address - Phone:480-964-2908
Mailing Address - Fax:480-833-2136
Practice Address - Street 1:2940 E BANNER GATEWAY DR
Practice Address - Street 2:SUITE 200
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2168
Practice Address - Country:US
Practice Address - Phone:480-964-2908
Practice Address - Fax:480-833-2136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ20WCHFCOMedicare ID - Type UnspecifiedGROUP NUMBER