MEDICARE: MESA MEDICAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R34642	NM

General Provider Information

NPI Number	:	1154416584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MESA MEDICAL LLC

Provider Business Mailing Address
First Line	:	260 MILLS AVE
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4125
Country	:	US
Telephone Number	:	505-425-6731
Fax Number	:	505-454-9193

Provider Business Practice Location Address
First Line	:	260 MILLS AVE
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4125
Country	:	US
Telephone Number	:	505-425-6731
Fax Number	:	505-454-9193

Authorized Official
Title or Position	:	OWNER
Name	:	MS. MARCIA L HEFKER
Credential	:	FNP-C
Telephone Number	:	505-425-6731

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	08/22/2020

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