=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467851246
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTA MARIE BERMEJILLO-VASQUEZ MPAS, PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2014
-----------------------------------------------------
Last Update Date | 08/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6900 N 10TH ST STE 3
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78504-3151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-682-1591
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2113 LEMON TREE CT
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78539-6357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-356-8560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA09080
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------