Provider Demographics
NPI:1710466396
Name:ROSA, MYRNA LIZZET
Entity Type:Individual
Prefix:MRS
First Name:MYRNA
Middle Name:LIZZET
Last Name:ROSA
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 1:177 MEADOW LOOP
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78582-6854
Mailing Address - Country:US
Mailing Address - Phone:956-573-4005
Mailing Address - Fax:
Practice Address - Street 1:2530 CENTRAL PALM DR
Practice Address - Street 2:
Practice Address - City:RIO GRANDE CITY
Practice Address - State:TX
Practice Address - Zip Code:78582-6648
Practice Address - Country:US
Practice Address - Phone:956-487-3996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2084661225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant