Basic Information
| Provider Information | |||||||||
| NPI: | 1710233366 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SALDIVAR | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | AARON | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 W REYNOSA AVE | ||||||||
| Address2: | |||||||||
| City: | DE LEON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764441630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548935895 | ||||||||
| FaxNumber: | 2548935222 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 RIVER NORTH BLVD | ||||||||
| Address2: | |||||||||
| City: | STEPHENVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764011804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2549652810 | ||||||||
| FaxNumber: | 2549655440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2012 | ||||||||
| LastUpdateDate: | 08/29/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA07921 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 310072902 | 05 | TX | MEDICAID |