Provider Demographics
NPI:1386456499
Name:RODRIGUEZ, PEDRO ALONZO (PA-C)
Entity type:Individual
Prefix:
First Name:PEDRO
Middle Name:ALONZO
Last Name:RODRIGUEZ
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:PEDRO
Other - Middle Name:ALOZO
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:135 BREMEN WAY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6949
Mailing Address - Country:US
Mailing Address - Phone:662-251-5417
Mailing Address - Fax:
Practice Address - Street 1:2100 US-61
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183
Practice Address - Country:US
Practice Address - Phone:601-883-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-24
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS390200000X
MSPA00888363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program