Basic Information
| Provider Information | |||||||||
| NPI: | 1235532235 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORDOVA | ||||||||
| FirstName: | MAYRA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 PAPPAS ST | ||||||||
| Address2: | |||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780411705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567958100 | ||||||||
| FaxNumber: | 9567186294 | ||||||||
| Practice Location | |||||||||
| Address1: | 1515 PAPPAS ST | ||||||||
| Address2: | |||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780411705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567958100 | ||||||||
| FaxNumber: | 9567186294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2014 | ||||||||
| LastUpdateDate: | 10/03/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1119088 PA | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1119088 | 01 | TX | PA CERTIFICATE | OTHER |