1639801038 NPI number — MRS. ITZA GARZA LUCKIE PA-C

Table of content: MRS. ITZA GARZA LUCKIE PA-C (NPI 1639801038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639801038 NPI number — MRS. ITZA GARZA LUCKIE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUCKIE
Provider First Name:
ITZA
Provider Middle Name:
GARZA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GARZA
Provider Other First Name:
ITZA
Provider Other Middle Name:
ANNETTE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639801038
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201 W UNIVERSITY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDINBURG
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78539-2909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-665-7049
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2101 PEASE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARLINGEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78550-8307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-389-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2022

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: 363A00000X , with the licence number:  PA16529 , 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)