Basic Information
| Provider Information | |||||||||
| NPI: | 1023144193 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MESA | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 CEDAR TER | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287394516 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 165 COOLRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287922767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286943939 | ||||||||
| FaxNumber: | 8286920533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 103090 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 147223XX | 01 | PREFERRED CARE | OTHER | P00163937 | 01 | RAILROAD INSURANCE | OTHER | P61859 | 01 | HUMA HUMANA | OTHER | P00163937 | 01 | RAILROAD | OTHER | 348944C | 05 | NC | MEDICAID | 348944A | 05 | NC | MEDICAID | D1819 | 01 | MEDCOST PREFERRED | OTHER | 103090 | 01 | NC | STATE LICENSE NUMBER | OTHER | 8913525 | 05 | NC | MEDICAID | DB5806 | 01 | RAILROAD | OTHER |