Provider Demographics
NPI:1790139699
Name:MATA GONZALEZ, LUIS ALBERTO (FNP)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ALBERTO
Last Name:MATA GONZALEZ
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 TOM GILL RD
Mailing Address - Street 2:
Mailing Address - City:PENITAS
Mailing Address - State:TX
Mailing Address - Zip Code:78576-7352
Mailing Address - Country:US
Mailing Address - Phone:956-458-1135
Mailing Address - Fax:
Practice Address - Street 1:605 N MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:DONNA
Practice Address - State:TX
Practice Address - Zip Code:78537-2726
Practice Address - Country:US
Practice Address - Phone:956-464-4407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-17
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP130908363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily