Basic Information
| Provider Information | |||||||||
| NPI: | 1568778116 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORDERO | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844658 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547242111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 600 N PARK ST | ||||||||
| Address2: | |||||||||
| City: | BRENHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778332610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9793375800 | ||||||||
| FaxNumber: | 9792779074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2010 | ||||||||
| LastUpdateDate: | 08/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1951 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 5601003549 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 2116 | NE | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA08180 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.