Healthcare Provider Details

I. General information

NPI: 1265415525
Provider Name (Legal Business Name): NATALIE ANGELE MATTOS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 6TH ST
MODESTO CA
95354-2203
US

IV. Provider business mailing address

PO BOX 2906
TURLOCK CA
95381-2906
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-2845
  • Fax: 209-236-1290
Mailing address:
  • Phone: 209-892-3111
  • Fax: 209-892-3112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA18095
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: