Provider Demographics
NPI:1366608648
Name:MESA, JOHNEMMA MARIE CALIWANAGAN (RPT)
Entity type:Individual
Prefix:
First Name:JOHNEMMA MARIE
Middle Name:CALIWANAGAN
Last Name:MESA
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8604 96TH ST APT A6
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-1751
Mailing Address - Country:US
Mailing Address - Phone:347-255-6152
Mailing Address - Fax:
Practice Address - Street 1:53 ELIZABETH ST FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4623
Practice Address - Country:US
Practice Address - Phone:212-966-9818
Practice Address - Fax:212-966-9189
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-05
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027704225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400086394Medicare PIN
NYA400026185Medicare PIN