Healthcare Provider Details

I. General information

NPI: 1023913159
Provider Name (Legal Business Name): HEIDEE MICHALLE CORDOVA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

A6 VILLA MARIA
MANATI PR
00674-4679
US

IV. Provider business mailing address

A6 VILLA MARIA
MANATI PR
00674-4679
US

V. Phone/Fax

Practice location:
  • Phone: 787-447-9155
  • Fax:
Mailing address:
  • Phone: 787-447-9155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3312
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: