Provider Demographics
NPI:1871619171
Name:DEZELAN, MARIANNE K (PAC)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:K
Last Name:DEZELAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:MARIANNE
Other - Middle Name:
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 1730
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1058
Mailing Address - Country:US
Mailing Address - Phone:760-568-2684
Mailing Address - Fax:760-341-5832
Practice Address - Street 1:39000 BOB HOPE DR, HIRSCHBERG BLG, STE 310
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270
Practice Address - Country:US
Practice Address - Phone:760-568-2684
Practice Address - Fax:760-341-5832
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14742363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS73462Medicare UPIN
CAOPA147420Medicare PIN