MEDICARE: KIMBERLY MATTA 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	PA08479	TX
2	363A00000X	Physician Assistant	2204	CO
3	363A00000X	Physician Assistant	PA8479	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407949985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY MATTA PA-C

Provider Business Mailing Address
First Line	:	929 GESSNER RD STE 2200
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77024-2583
Country	:	US
Telephone Number	:	713-337-5277
Fax Number	:

Provider Business Practice Location Address
First Line	:	18400 KATY FWY
Second Line	:	SUITE 530
City	:	HOUSTON
State	:	TX
Zip	:	77094-1286
Country	:	US
Telephone Number	:	281-717-4003
Fax Number	:	281-206-7597

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

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	01/18/2019

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Directions to “ KIMBERLY MATTA PA-C” Practice Location

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