MEDICARE: MRS. MARY MATELAN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0014X	Interventional Pain Medicine Physician	PA9110783	FL
2	363AM0700X	Medical Physician Assistant
3	363AS0400X	Surgical Physician Assistant
4	363A00000X	Physician Assistant	PA9110783	FL

General Provider Information

NPI Number	:	1902319841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY MATELAN PA-C

Provider Business Mailing Address
First Line	:	7855 38TH AVE N
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33710-1152
Country	:	US
Telephone Number	:	727-341-2408
Fax Number	:

Provider Business Practice Location Address
First Line	:	7855 38TH AVE N
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33710-1152
Country	:	US
Telephone Number	:	727-341-2408
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2017
Last Update Date	:	03/19/2020

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