Provider Demographics
NPI:1053341404
Name:MADRIGAL, MIGUEL A (PAC)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:A
Last Name:MADRIGAL
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 PAPPAS ST
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-6510
Mailing Address - Country:US
Mailing Address - Phone:956-795-8101
Mailing Address - Fax:956-795-8135
Practice Address - Street 1:1515 PAPPAS ST
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-1705
Practice Address - Country:US
Practice Address - Phone:956-795-8101
Practice Address - Fax:956-795-8135
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02596363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA02596OtherLICENSE NUMBER
TX307071601Medicaid
TXTXB151700Medicare Oscar/Certification
TXH99423Medicare UPIN
TX451960Medicare PIN
TX451961Medicare PIN
TX163022001Medicaid
TX83N865Medicare PIN
TXPA02596OtherLICENSE NUMBER