Provider Demographics
NPI:1881683993
Name:CORDOVA, MYRNA I (RPT)
Entity Type:Individual
Prefix:MRS
First Name:MYRNA
Middle Name:I
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4375
Mailing Address - Street 2:
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00694-4375
Mailing Address - Country:US
Mailing Address - Phone:787-858-4845
Mailing Address - Fax:787-858-4845
Practice Address - Street 1:CARR #2 KM 40.5
Practice Address - Street 2:PLAZA JARDINEZ
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693
Practice Address - Country:US
Practice Address - Phone:787-858-4845
Practice Address - Fax:787-858-4845
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR655225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0084190OtherMEDICARE PROVIDER NUMBER