Provider Demographics
NPI:1023144193
Name:MESA, GREGORY ROBERT (PA-C)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ROBERT
Last Name:MESA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2670 MILLS PARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-5005
Mailing Address - Country:US
Mailing Address - Phone:803-985-3939
Mailing Address - Fax:
Practice Address - Street 1:2670 MILLS PARK DR STE 200
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-5005
Practice Address - Country:US
Practice Address - Phone:803-985-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103090363A00000X
SC5442363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC348944CMedicaid
NC348944AMedicaid
550847506OtherSE MEDICARE COMPLETE
550847506OtherWORKERS COMP
DB5806OtherRAILROAD
P00163937OtherRAILROAD
P00163937OtherRAILROAD INSURANCE
P61859OtherHUMA HUMANA
NC103090OtherSTATE LICENSE NUMBER
147223XXOtherPREFERRED CARE
550847506OtherCHAMPUS
550847506OtherCOMMERCIAL INSURANCE
550847506OtherHUMANA
NC8913525Medicaid
D1819OtherMEDCOST PREFERRED
267311481OtherCHAMPUS
SC5442OtherSTATE LICENSE NUMBER