Basic Information
| Provider Information | |||||||||
| NPI: | 1649474198 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | MARIVEL | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 MISTLETOE BLVD STE 100 | ||||||||
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| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173381300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 209 OLD HIGHWAY 1187 | ||||||||
| Address2: | |||||||||
| City: | BURLESON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760280281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173381300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 11/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA03757 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.