Provider Demographics
NPI:1861855835
Name:GONZALEZ-MATOS, YAIMA (RD, LND)
Entity Type:Individual
Prefix:
First Name:YAIMA
Middle Name:
Last Name:GONZALEZ-MATOS
Suffix:
Gender:F
Credentials:RD, LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:487 CALLE LIRIO
Mailing Address - Street 2:URBANIZACION MANCIONES DE RIO PIEDRAS
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-545-8808
Mailing Address - Fax:
Practice Address - Street 1:CARR 165 KM 4.5
Practice Address - Street 2:BO QUEBRADA CRUZ
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953
Practice Address - Country:US
Practice Address - Phone:787-545-8808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1904133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRIK978AMedicare UPIN