Basic Information
| Provider Information | |||||||||
| NPI: | 1720060890 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MESQUITE MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 BERTHA HOWE AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | MESQUITE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890277502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023460800 | ||||||||
| FaxNumber: | 7023460801 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 BERTHA HOWE AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | MESQUITE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890277502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023460800 | ||||||||
| FaxNumber: | 7023460801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GATHERUM | ||||||||
| AuthorizedOfficialFirstName: | LLOYD | ||||||||
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| AuthorizedOfficialTitleorPosition: | C.F.O. | ||||||||
| AuthorizedOfficialTelephone: | 7023460800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | B355 | NV | X | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 207Q00000X | APN00314 | NV | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 8194 | NV | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 97 | NV | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 0841 | NV | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 10328 | NV | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 10669 | NV | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | PIN#38138 | 01 | NV | LEO BLACK, DC | OTHER | 811621 | 05 | AZ | MEDICAID | PIN#37972 | 01 | NV | ENRIQUE ALFARO, MD | OTHER | PIN#32238 | 01 | NV | LONNIE EMPEY, DO | OTHER | 811580 | 05 | AZ | MEDICAID | 811598 | 05 | AZ | MEDICAID | PIN#36266 | 01 | NV | JEFFREY WRIGHT, PAC | OTHER |