Basic Information
| Provider Information | |||||||||
| NPI: | 1285812859 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENRIQUEZ | ||||||||
| FirstName: | RODOLFO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | OPA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ENRIQUEZ | ||||||||
| OtherFirstName: | RUDY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | JR. | ||||||||
| OtherCredential: | OPA-C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1901 LONG PRAIRIE RD STE 220-80 | ||||||||
| Address2: | |||||||||
| City: | FLOWER MOUND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750224246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142272457 | ||||||||
| FaxNumber: | 2147640888 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 LONG PRAIRIE RD STE 220-80 | ||||||||
| Address2: | |||||||||
| City: | FLOWER MOUND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750224246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142272457 | ||||||||
| FaxNumber: | 2147640880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2008 | ||||||||
| LastUpdateDate: | 09/11/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | OPAC990 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | OPA-C990 | 01 | NBCOPA | OTHER |