Healthcare Provider Details

I. General information

NPI: 1639624059
Provider Name (Legal Business Name): JANNIFER MARIE MATOS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2016
Last Update Date: 01/08/2022
Certification Date: 01/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11750 SW 40TH ST
MIAMI FL
33175-3530
US

IV. Provider business mailing address

6365 COLLINS AVE APT 3703
MIAMI BEACH FL
33141-9613
US

V. Phone/Fax

Practice location:
  • Phone: 305-223-3000
  • Fax:
Mailing address:
  • Phone: 305-733-1094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9110888
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: