Healthcare Provider Details

I. General information

NPI: 1811345879
Provider Name (Legal Business Name): JKMATIBAG, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7878 N 16TH ST SUITE 250
PHOENIX AZ
85020-4449
US

IV. Provider business mailing address

7878 N 16TH ST SUITE 250
PHOENIX AZ
85020-4449
US

V. Phone/Fax

Practice location:
  • Phone: 602-395-0718
  • Fax: 602-277-8146
Mailing address:
  • Phone: 602-395-0718
  • Fax: 602-277-8146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number52115
License Number StateAZ

VIII. Authorized Official

Name: JOSE A MATIBAG
Title or Position: OWNER
Credential: MD
Phone: 602-395-0718