Provider Demographics
NPI:1073127817
Name:MATA, JOSE LUIS JR (PTA)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:MATA
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 SAN BERNARDO AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-5718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4500 SAN BERNARDO AVE STE 108
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-5718
Practice Address - Country:US
Practice Address - Phone:956-284-0100
Practice Address - Fax:956-284-0100
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2155064225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant