Basic Information
| Provider Information | |||||||||
| NPI: | 1104805001 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATTOX | ||||||||
| FirstName: | PENN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1955 1ST AVENUE NORTH | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SAINT PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337138907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278223500 | ||||||||
| FaxNumber: | 7278223228 | ||||||||
| Practice Location | |||||||||
| Address1: | 4215 EDGEWATER DR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328042206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075392000 | ||||||||
| FaxNumber: | 4073980050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA3280 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA380 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 2920905 00 | 05 | FL | MEDICAID | E4034Y | 01 | FL | FL MCARE - QSS SOUTHEAST CLINICAL SERVICES | OTHER |