Healthcare Provider Details

I. General information

NPI: 1659776987
Provider Name (Legal Business Name): ELIZABETH F. MATESA P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2014
Last Update Date: 10/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 ST. PAUL PLACE LOBBY LEVEL
BALTIMORE MD
21202
US

IV. Provider business mailing address

301 ST. PAUL PLACE MEDICAL STAFF OFFICE
BALTIMORE MD
21202
US

V. Phone/Fax

Practice location:
  • Phone: 410-539-2227
  • Fax:
Mailing address:
  • Phone: 410-659-2802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC05608
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: