Healthcare Provider Details

I. General information

NPI: 1861772295
Provider Name (Legal Business Name): MATIYAGA RAMIREZ JARDINIANO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4844 BERRYWOOD RD.
VA. BEACH VA
23464-5871
US

IV. Provider business mailing address

4844 BERRYWOOD RD.
VA. BEACH VA
23464-5871
US

V. Phone/Fax

Practice location:
  • Phone: 757-962-0778
  • Fax:
Mailing address:
  • Phone: 757-962-0778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110840340
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: