Provider Demographics
NPI:1497114060
Name:GARCIA-MATEO, ETHYANN ARLENE
Entity Type:Individual
Prefix:
First Name:ETHYANN
Middle Name:ARLENE
Last Name:GARCIA-MATEO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CALLE CORRIENTES
Mailing Address - Street 2:
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-6140
Mailing Address - Country:US
Mailing Address - Phone:787-370-3252
Mailing Address - Fax:
Practice Address - Street 1:20 CALLE CORRIENTES
Practice Address - Street 2:
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976-6140
Practice Address - Country:US
Practice Address - Phone:787-370-3252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-11
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22504207RI0200X, 390200000X
PR13952208D00000X
PR34982-R390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice