MEDICARE: ELLEN L MATTA CRNA

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	367500000X	Certified Registered Nurse Anesthetist	CRNA0158	AZ

General Provider Information

NPI Number	:	1497772115
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN L MATTA CRNA

Provider Business Mailing Address
First Line	:	2610 E UNIVERSITY DR
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85213-8436
Country	:	US
Telephone Number	:	480-892-8400
Fax Number	:	480-892-1889

Provider Business Practice Location Address
First Line	:	2610 E UNIVERSITY DR
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85213-8436
Country	:	US
Telephone Number	:	480-892-8400
Fax Number	:	480-892-1889

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

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	04/05/2017

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