Healthcare Provider Details

I. General information

NPI: 1093765323
Provider Name (Legal Business Name): ELIZABETH A MATTESI PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1223 GATEWAY DR
MELBOURNE FL
32901
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-728-6002
  • Fax: 321-676-9731
Mailing address:
  • Phone: 321-728-6002
  • Fax: 321-676-9731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA3294
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: