Provider Demographics
NPI:1750823134
Name:VASQUEZ, MATTHEW (LAT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17450 ST LUKES WAY
Mailing Address - Street 2:MAC III, SUITE 350
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77384-8044
Mailing Address - Country:US
Mailing Address - Phone:936-266-3130
Mailing Address - Fax:
Practice Address - Street 1:17450 ST LUKES WAY
Practice Address - Street 2:MAC III, SUITE 350
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77384-8044
Practice Address - Country:US
Practice Address - Phone:936-266-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT5868174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist