Healthcare Provider Details

I. General information

NPI: 1508236241
Provider Name (Legal Business Name): KRISTINA MATA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9329 STATE HWY 75 S.
NEW WAVERLY TX
77358
US

IV. Provider business mailing address

24 LONG HORN LOOP
NEW WAVERLY TX
77358-3735
US

V. Phone/Fax

Practice location:
  • Phone: 936-284-2055
  • Fax:
Mailing address:
  • Phone: 936-284-2055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP127389
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: