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General NPI Number Information
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NPI Number | 1174052229
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Entity Type | Individual
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Provider Name | EDINSON ANTONIO MATOS-MORENO SA-C
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Gender | Male
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Dates
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Enumeration Date | 06/11/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 705 SW 148TH AVE APT 202
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City | DAVIE
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State | FL
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Zip | 33325
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Country | US
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Telephone | 954-801-8559
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Fax |
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Provider Business Mailing Address
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Address Line | 701 SW 148TH AVE APT 101
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City | DAVIE
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State | FL
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Zip | 33325-3080
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Country | US
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Telephone | 954-801-8559
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number | 14-481
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License Number State | FL
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