Basic Information
Provider Information | |||||||||
NPI: | 1568942480 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RODRIGUEZ | ||||||||
FirstName: | IVONNE | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 734 | ||||||||
Address2: |   | ||||||||
City: | SANDIA PARK | ||||||||
State: | NM | ||||||||
PostalCode: | 870470734 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5053664193 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5801 S FASHION BLVD STE 180 | ||||||||
Address2: |   | ||||||||
City: | MURRAY | ||||||||
State: | UT | ||||||||
PostalCode: | 841078135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8012627246 | ||||||||
FaxNumber: | 8012623442 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2018 | ||||||||
LastUpdateDate: | 08/20/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9879378-1206 | UT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.