=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013663343
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLIE MATA CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2022
-----------------------------------------------------
Last Update Date | 02/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4725 N. FEDERAL HWY
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33308-4603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-771-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2006 HOGBACK RD SUITE 5A
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-263-2414
-----------------------------------------------------
Fax | 734-773-3471
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 9347349
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | APRN11033142
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------