Basic Information
| Provider Information | |||||||||
| NPI: | 1790129815 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATA | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | GUADALUPE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7913 BANDERA RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782506511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106989841 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18707 HARDY OAK BLVD STE 530 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782584791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104958280 | ||||||||
| FaxNumber: | 2104813116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2013 | ||||||||
| LastUpdateDate: | 09/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 619179 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.