Healthcare Provider Details

I. General information

NPI: 1003250473
Provider Name (Legal Business Name): MESA INDIANA ED ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2013
Last Update Date: 04/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1792 ALYSHEBA WAY SUITE 150
LEXINGTON KY
40509-2288
US

IV. Provider business mailing address

1792 ALYSHEBA WAY SUITE 150
LEXINGTON KY
40509-2288
US

V. Phone/Fax

Practice location:
  • Phone: 859-335-9041
  • Fax:
Mailing address:
  • Phone: 859-335-9041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARK VALENTINE
Title or Position: CFO
Credential:
Phone: 859-335-9041