Healthcare Provider Details

I. General information

NPI: 1366397010
Provider Name (Legal Business Name): SOL MESA MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2026
Last Update Date: 02/27/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 NM-564
GALLUP NM
87301
US

IV. Provider business mailing address

2418 E HISTORIC HIGHWAY 66 # 292
GALLUP NM
87301-4767
US

V. Phone/Fax

Practice location:
  • Phone: 505-522-3681
  • Fax: 505-473-9552
Mailing address:
  • Phone: 505-522-3681
  • Fax: 505-473-9552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSEPH LEE ELIASON
Title or Position: CO-OWNER
Credential: CNP
Phone: 505-906-6581