Provider Demographics
NPI:1750162921
Name:ELIZONDO, EMMANUEL EDUARDO
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:EDUARDO
Last Name:ELIZONDO
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 1:124 S US HIGHWAY 83 UNIT 8
Mailing Address - Street 2:
Mailing Address - City:ZAPATA
Mailing Address - State:TX
Mailing Address - Zip Code:78076-3813
Mailing Address - Country:US
Mailing Address - Phone:956-750-6592
Mailing Address - Fax:
Practice Address - Street 1:124 S US HIGHWAY 83 UNIT 8
Practice Address - Street 2:
Practice Address - City:ZAPATA
Practice Address - State:TX
Practice Address - Zip Code:78076-3813
Practice Address - Country:US
Practice Address - Phone:956-750-6592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX856927163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator