Healthcare Provider Details

I. General information

NPI: 1922027168
Provider Name (Legal Business Name): TANIA MILAD MATTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 KEENE ROAD
WEST RICHLAND WA
99353
US

IV. Provider business mailing address

3900 S ZINTEL WAY
KENNEWICK WA
99338
US

V. Phone/Fax

Practice location:
  • Phone: 509-942-3130
  • Fax: 509-628-8335
Mailing address:
  • Phone: 509-942-3627
  • Fax: 509-942-2268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number01060593
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMD00048517
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: