Healthcare Provider Details

I. General information

NPI: 1760137178
Provider Name (Legal Business Name): RAFAEL MATOS APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2022
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15511 N FLORIDA AVE STE A3
TAMPA FL
33613-1263
US

IV. Provider business mailing address

15511 N FLORIDA AVE STE A3
TAMPA FL
33613-1263
US

V. Phone/Fax

Practice location:
  • Phone: 813-473-8373
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11018042
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: