Provider Demographics
NPI:1780865857
Name:MATA, ISAIAS JR (PA)
Entity Type:Individual
Prefix:MR
First Name:ISAIAS
Middle Name:
Last Name:MATA
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 MICHAEL ANGELO
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-1403
Mailing Address - Country:US
Mailing Address - Phone:956-217-7000
Mailing Address - Fax:956-682-1960
Practice Address - Street 1:2717 MICHAEL ANGELO
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-1403
Practice Address - Country:US
Practice Address - Phone:956-217-7000
Practice Address - Fax:956-682-1960
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03404363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA03404OtherTEXAS LICENSE
TXQ04841Medicare UPIN
TX8B3193Medicare PIN