MEDICARE: LUIS FERNANDO RODRIGUEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1760030712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUIS FERNANDO RODRIGUEZ

Provider Business Mailing Address
First Line	:	5001 S COOPER ST STE 201
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76017-5993
Country	:	US
Telephone Number	:	866-367-8768
Fax Number	:

Provider Business Practice Location Address
First Line	:	6801 OAKMONT BLVD STE 102
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3903
Country	:	US
Telephone Number	:	866-367-8768
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/03/2019
Last Update Date	:	03/03/2023

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