Healthcare Provider Details

I. General information

NPI: 1255153706
Provider Name (Legal Business Name): PAUL MATA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4643 RIM CIR APT 204
CARLSBAD CA
92010-4679
US

IV. Provider business mailing address

2988 WOODBURY CT
CARLSBAD CA
92010-6545
US

V. Phone/Fax

Practice location:
  • Phone: 760-224-8361
  • Fax:
Mailing address:
  • Phone: 760-847-0334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95038362
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95038362
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: