Healthcare Provider Details

I. General information

NPI: 1477410587
Provider Name (Legal Business Name): PAUL MATOS-GONZALES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2026
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 NW 11TH ST APT 609
MIAMI FL
33136-2244
US

IV. Provider business mailing address

1170 NW 11TH ST APT 609
MIAMI FL
33136-2244
US

V. Phone/Fax

Practice location:
  • Phone: 570-807-6898
  • Fax:
Mailing address:
  • Phone: 570-807-6898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11041959
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: