Provider Demographics
NPI:1801618996
Name:MATA, GLENDA ELIZABETH
Entity type:Individual
Prefix:
First Name:GLENDA
Middle Name:ELIZABETH
Last Name:MATA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 N 40TH LN
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-3307
Mailing Address - Country:US
Mailing Address - Phone:956-336-7412
Mailing Address - Fax:
Practice Address - Street 1:5502 S MCCOLL RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-8747
Practice Address - Country:US
Practice Address - Phone:956-362-4451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1178177363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics