Basic Information
| Provider Information | |||||||||
| NPI: | 1831381458 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORDOBA KISSEE | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5358 | ||||||||
| Address2: | |||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785025358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563625673 | ||||||||
| FaxNumber: | 9563622038 | ||||||||
| Practice Location | |||||||||
| Address1: | 5500 RAPHAEL DR | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785391407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563625673 | ||||||||
| FaxNumber: | 9563622038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2007 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
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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 | 207RE0101X | 41885 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RE0101X | P7092 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 468517 | 05 | AZ | MEDICAID | 333675206 | 01 | TX | MEDICAID-CSHCN | OTHER | 333675205 | 05 | TX | MEDICAID |