Healthcare Provider Details

I. General information

NPI: 1467953281
Provider Name (Legal Business Name): ERICKSON MATA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 CHERRY RIDGE ST STE 400
SAN ANTONIO TX
78230-4820
US

IV. Provider business mailing address

11710 PARLIAMENT ST APT 706
SAN ANTONIO TX
78213-1167
US

V. Phone/Fax

Practice location:
  • Phone: 210-692-0222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number189977
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: