Provider Demographics
NPI:1568942480
Name:RODRIGUEZ, IVONNE A (PA-C)
Entity Type:Individual
Prefix:
First Name:IVONNE
Middle Name:A
Last Name:RODRIGUEZ
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:PO BOX 734
Mailing Address - Street 2:
Mailing Address - City:SANDIA PARK
Mailing Address - State:NM
Mailing Address - Zip Code:87047-0734
Mailing Address - Country:US
Mailing Address - Phone:505-366-4193
Mailing Address - Fax:
Practice Address - Street 1:5801 S FASHION BLVD STE 180
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-8135
Practice Address - Country:US
Practice Address - Phone:801-262-7246
Practice Address - Fax:801-262-3442
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9879378-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant