Provider Demographics
NPI:1588201115
Name:RODRIGUEZ MANCEBO, NATASHA VICTORIA (PA-C)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:VICTORIA
Last Name:RODRIGUEZ MANCEBO
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 1:2214 N UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-3221
Mailing Address - Country:US
Mailing Address - Phone:309-680-7669
Mailing Address - Fax:309-681-8443
Practice Address - Street 1:711 W JOHN GWYNN AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605-2270
Practice Address - Country:US
Practice Address - Phone:309-680-7600
Practice Address - Fax:309-671-2188
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085007443363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant