Healthcare Provider Details

I. General information

NPI: 1497772115
Provider Name (Legal Business Name): ELLEN L MATTA CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 E UNIVERSITY DR
MESA AZ
85213-8436
US

IV. Provider business mailing address

2610 E UNIVERSITY DR
MESA AZ
85213-8436
US

V. Phone/Fax

Practice location:
  • Phone: 480-892-8400
  • Fax: 480-892-1889
Mailing address:
  • Phone: 480-892-8400
  • Fax: 480-892-1889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA0158
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: