MEDICARE: MRS. JESSICA LYNN MATANDE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	MA056228	PA
2	363A00000X	Physician Assistant	OA003485	PA

General Provider Information

NPI Number	:	1326480427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA LYNN MATANDE PA-C

Provider Business Mailing Address
First Line	:	25 WASHINGTON LN APT 729
Second Line	:
City	:	WYNCOTE
State	:	PA
Zip	:	19095-1422
Country	:	US
Telephone Number	:	913-961-8670
Fax Number	:

Provider Business Practice Location Address
First Line	:	325 W GERMANTOWN PIKE
Second Line	:
City	:	EAST NORRITON
State	:	PA
Zip	:	19403-4207
Country	:	US
Telephone Number	:	610-272-1881
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2013
Last Update Date	:	11/17/2020

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