Healthcare Provider Details

I. General information

NPI: 1134731268
Provider Name (Legal Business Name): IMELDA MIRANDA MATA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 DECLARATION DR
CHICO CA
95973-4900
US

IV. Provider business mailing address

4944 WILL T RD
CHICO CA
95973-9411
US

V. Phone/Fax

Practice location:
  • Phone: 530-894-6832
  • Fax:
Mailing address:
  • Phone: 530-521-0291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number56624
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: