1023144193 NPI number — MR. GREGORY ROBERT MESA PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023144193 NPI number — MR. GREGORY ROBERT MESA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MESA
Provider First Name:
GREGORY
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023144193
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 CEDAR TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENDERSONVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28739-4516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
165 COOLRIDGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENDERSONVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28792-2767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-694-3939
Provider Business Practice Location Address Fax Number:
828-692-0533
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  103090 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 147223XX . This is a "PREFERRED CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00163937 . This is a "RAILROAD INSURANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P61859 . This is a "HUMA HUMANA" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00163937 . This is a "RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 348944C , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 348944A , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: D1819 . This is a "MEDCOST PREFERRED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 103090 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8913525 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: DB5806 . This is a "RAILROAD" identifier . This identifiers is of the category "OTHER".




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