MEDICARE: JESUS MESA GONZALEZ JR. PA-C

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	363A00000X	Physician Assistant	PA04958	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA04958	OTHER	TX	TEXAS MEDICAL BOARD

General Provider Information

NPI Number	:	1336336288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESUS MESA GONZALEZ JR. PA-C

Provider Business Mailing Address
First Line	:	6912 FM 1488 RD
Second Line	:	STE A
City	:	MAGNOLIA
State	:	TX
Zip	:	77354-1527
Country	:	US
Telephone Number	:	281-356-1945
Fax Number	:	281-356-1978

Provider Business Practice Location Address
First Line	:	1510 HANNA VALLEY RD
Second Line	:
City	:	GOLDTHWAITE
State	:	TX
Zip	:	76844-2533
Country	:	US
Telephone Number	:	325-648-2263
Fax Number	:	325-648-6303

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2007
Last Update Date	:	11/08/2021

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