Provider Demographics
NPI:1093298036
Name:MESQUITE WALK IN CLINIC, PLLC
Entity Type:Organization
Organization Name:MESQUITE WALK IN CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:DIANNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-222-8001
Mailing Address - Street 1:910 N GALLOWAY AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-2409
Mailing Address - Country:US
Mailing Address - Phone:972-222-8001
Mailing Address - Fax:469-802-6272
Practice Address - Street 1:910 N GALLOWAY AVE STE 102
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-2409
Practice Address - Country:US
Practice Address - Phone:972-222-8001
Practice Address - Fax:469-802-6272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1154746105OtherNPPES