Healthcare Provider Details

I. General information

NPI: 1053953273
Provider Name (Legal Business Name): MARINA MATTA PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2019
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17108 MACK AVE STE 108
GROSSE POINTE FARMS MI
48230-6224
US

IV. Provider business mailing address

17108 MACK AVE STE 108
GROSSE POINTE FARMS MI
48230-6224
US

V. Phone/Fax

Practice location:
  • Phone: 313-723-2572
  • Fax:
Mailing address:
  • Phone: 313-723-2572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: