Provider Demographics
NPI:1881714632
Name:MESA FAMILY PRACTICE PC
Entity type:Organization
Organization Name:MESA FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:DEKAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-325-2323
Mailing Address - Street 1:2130A FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401
Mailing Address - Country:US
Mailing Address - Phone:505-325-2323
Mailing Address - Fax:505-325-7172
Practice Address - Street 1:2130A FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-325-2323
Practice Address - Fax:505-325-7172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM95222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F64297Medicare UPIN
I02353Medicare UPIN
PA00019Medicare ID - Type UnspecifiedDR PERCELL
P07741Medicare UPIN
P11640Medicare UPIN
7200521003Medicare ID - Type UnspecifiedGR