Provider Demographics
NPI:1174266795
Name:RODRIGUEZ MATA, NITCHELLE AIDEE (PA-C)
Entity Type:Individual
Prefix:
First Name:NITCHELLE
Middle Name:AIDEE
Last Name:RODRIGUEZ MATA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 S L ST APT 2
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78503-1903
Mailing Address - Country:US
Mailing Address - Phone:956-388-0443
Mailing Address - Fax:
Practice Address - Street 1:208 STARR ST
Practice Address - Street 2:
Practice Address - City:MERCEDES
Practice Address - State:TX
Practice Address - Zip Code:78570-2734
Practice Address - Country:US
Practice Address - Phone:956-514-1643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA15602208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA15602OtherLICENSE