Provider Demographics
NPI:1508236241
Name:MATA, KRISTINA (FNP-C)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:MATA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 LONG HORN LOOP
Mailing Address - Street 2:
Mailing Address - City:NEW WAVERLY
Mailing Address - State:TX
Mailing Address - Zip Code:77358-3735
Mailing Address - Country:US
Mailing Address - Phone:936-284-2055
Mailing Address - Fax:
Practice Address - Street 1:9329 STATE HWY 75 S.
Practice Address - Street 2:
Practice Address - City:NEW WAVERLY
Practice Address - State:TX
Practice Address - Zip Code:77358
Practice Address - Country:US
Practice Address - Phone:936-284-2055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127389363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily