Healthcare Provider Details

I. General information

NPI: 1962864728
Provider Name (Legal Business Name): DIEGO MASCORRO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 PAPPAS ST
LAREDO TX
78041-1705
US

IV. Provider business mailing address

PO BOX 3397
LAREDO TX
78044-3397
US

V. Phone/Fax

Practice location:
  • Phone: 956-718-6259
  • Fax: 956-718-6294
Mailing address:
  • Phone: 956-718-6259
  • Fax: 956-718-6294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: