MEDICARE: MAMMA MIA MEDICAL PC

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	363AM0700X	Medical Physician Assistant

General Provider Information

NPI Number	:	1992415962
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAMMA MIA MEDICAL PC

Provider Business Mailing Address
First Line	:	2474 WALNUT ST # 314
Second Line	:
City	:	CARY
State	:	NC
Zip	:	27518-9212
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4000 DUBLIN BLVD STE 150
Second Line	:
City	:	DUBLIN
State	:	CA
Zip	:	94568-3180
Country	:	US
Telephone Number	:	813-732-7842
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RYAN CATES
Credential	:	DMSC, MMS, PA-C
Telephone Number	:	813-732-7842

Provider Enumeration Date	:	12/01/2022
Last Update Date	:	12/01/2022

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