Provider Demographics
NPI:1790760486
Name:RODRIGUEZ, NICHOLE (PA)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SILVER SAGE DR
Mailing Address - Street 2:
Mailing Address - City:DEL RIO
Mailing Address - State:TX
Mailing Address - Zip Code:78840-2150
Mailing Address - Country:US
Mailing Address - Phone:830-719-3271
Mailing Address - Fax:
Practice Address - Street 1:1011 E 7TH ST
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-4162
Practice Address - Country:US
Practice Address - Phone:830-775-8513
Practice Address - Fax:830-774-1430
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03627363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP89371Medicare UPIN
TX8A7194Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER