Provider Demographics
NPI:1336985886
Name:MATUTE MENDOZA, INDIRA E (610-PA)
Entity type:Individual
Prefix:MS
First Name:INDIRA
Middle Name:E
Last Name:MATUTE MENDOZA
Suffix:
Gender:F
Credentials:610-PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13072
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00908-3072
Mailing Address - Country:US
Mailing Address - Phone:787-631-5924
Mailing Address - Fax:
Practice Address - Street 1:10000 AV. 65 DE INFANTERIA
Practice Address - Street 2:SHOPPING COURT, 2ND FLOOR
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00985
Practice Address - Country:US
Practice Address - Phone:787-200-7833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-03
Last Update Date:2024-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR610-P.A.363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical