1316410426 NPI number — MRS. MYRA LEIGH DE LA GARZA NP-C

Table of content: MRS. MYRA LEIGH DE LA GARZA NP-C (NPI 1316410426)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316410426 NPI number — MRS. MYRA LEIGH DE LA GARZA NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE LA GARZA
Provider First Name:
MYRA
Provider Middle Name:
LEIGH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316410426
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1612 E 30TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISSION
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78574-1788
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-248-6606
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3804 S JACKSON RD STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDINBURG
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78539-6683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-296-3041
Provider Business Practice Location Address Fax Number:
956-296-3040
Provider Enumeration Date:
01/10/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP139673 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 395081801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: H08KV811 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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