Provider Demographics
NPI:1760747471
Name:DE LA MATER, RAQUEL ALEJANDRA (NP)
Entity Type:Individual
Prefix:MRS
First Name:RAQUEL
Middle Name:ALEJANDRA
Last Name:DE LA MATER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:420 DELAWARE ST SE
Mailing Address - Street 2:MMC 195
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0341
Mailing Address - Country:US
Mailing Address - Phone:651-269-3246
Mailing Address - Fax:
Practice Address - Street 1:420 DELAWARE ST SE
Practice Address - Street 2:MMC 195
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0341
Practice Address - Country:US
Practice Address - Phone:612-624-5915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1942536390200000X, 363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology