Provider Demographics
NPI:1134225824
Name:NATIVIDAD, JAIME
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:NATIVIDAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5746 TROWBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-3341
Mailing Address - Country:US
Mailing Address - Phone:915-219-4300
Mailing Address - Fax:915-519-4300
Practice Address - Street 1:1907 E YANDELL DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-3416
Practice Address - Country:US
Practice Address - Phone:915-219-4300
Practice Address - Fax:915-519-4300
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX583765367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00C81QOtherBCBS
TX088958602Medicaid
579543Medicare UPIN
TX088958602Medicaid