Provider Demographics
NPI:1710873179
Name:MATA MAYORGA, ROBERTO
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:MATA MAYORGA
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 1:9012 Q ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68127-3549
Mailing Address - Country:US
Mailing Address - Phone:402-315-1000
Mailing Address - Fax:
Practice Address - Street 1:9012 Q ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68127-3549
Practice Address - Country:US
Practice Address - Phone:402-315-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-13
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide