Healthcare Provider Details

I. General information

NPI: 1215456827
Provider Name (Legal Business Name): EBEN DE MATTEO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2017
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9250 BLUE ASH RD
BLUE ASH OH
45242-6822
US

IV. Provider business mailing address

9250 BLUE ASH RD
BLUE ASH OH
45242-6822
US

V. Phone/Fax

Practice location:
  • Phone: 513-792-7445
  • Fax: 513-791-4042
Mailing address:
  • Phone: 513-792-7445
  • Fax: 513-791-4042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.005207RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: