Basic Information
| Provider Information | |||||||||
| NPI: | 1760747471 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE LA MATER | ||||||||
| FirstName: | RAQUEL | ||||||||
| MiddleName: | ALEJANDRA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 DELAWARE ST SE | ||||||||
| Address2: | MMC 195 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554550341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512693246 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 420 DELAWARE ST SE | ||||||||
| Address2: | MMC 195 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554550341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126245915 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2012 | ||||||||
| LastUpdateDate: | 08/09/2012 | ||||||||
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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 | 390200000X | R1942536 | MN | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363LA2200X | R1942536 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | R1942536 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.