Healthcare Provider Details

I. General information

NPI: 1164338547
Provider Name (Legal Business Name): PASQUALE MATERA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 WATERS PL
BRONX NY
10461-2728
US

IV. Provider business mailing address

25 COLONIAL DR APT B
NEW PALTZ NY
12561-1826
US

V. Phone/Fax

Practice location:
  • Phone: 719-631-2407
  • Fax:
Mailing address:
  • Phone: 845-745-6120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: