Healthcare Provider Details

I. General information

NPI: 1295643674
Provider Name (Legal Business Name): MIGUEL ANTONIO MATOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9916 GEORGETOWN PIKE
GREAT FALLS VA
22066
US

IV. Provider business mailing address

3812 ROXBURY CT
ALEXANDRIA VA
22309-3729
US

V. Phone/Fax

Practice location:
  • Phone: 310-857-0250
  • Fax:
Mailing address:
  • Phone: 310-857-0250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberB202405370
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: