Basic Information
| Provider Information | |||||||||
| NPI: | 1447455290 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATKIN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MATKIN | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | RAY PEREZ | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 22005 | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337422005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278232188 | ||||||||
| FaxNumber: | 7278280723 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 6TH ST S | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278232188 | ||||||||
| FaxNumber: | 7278280723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2007 | ||||||||
| LastUpdateDate: | 08/30/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | ARNP 9168845 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | G4357 | 01 | FL | BLUE CROSS BLUE SHEILD | OTHER | 308608900 | 05 | FL | MEDICAID | 59-3411711 | 01 | FL | GTBA | OTHER | 593072468 | 01 | FL | BAYFRONT ANESTHESIA SERVICES PA | OTHER |