Provider Demographics
NPI:1174050272
Name:MATA, AMANDA (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MATA
Suffix:
Gender:F
Credentials:PA
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 4449
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78502-4449
Mailing Address - Country:US
Mailing Address - Phone:956-682-1888
Mailing Address - Fax:956-661-2207
Practice Address - Street 1:100 E RIDGE RD STE A
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1346
Practice Address - Country:US
Practice Address - Phone:956-682-1888
Practice Address - Fax:956-661-2207
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-19
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF04170401363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner