Basic Information
| Provider Information | |||||||||
| NPI: | 1518912971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATA | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 CRAWFORD ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478074614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122315678 | ||||||||
| FaxNumber: | 8122314475 | ||||||||
| Practice Location | |||||||||
| Address1: | 302 W CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | BRECKENRIDGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486159579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898423118 | ||||||||
| FaxNumber: | 9898421110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 10001212A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 5601002771 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0852915110 | 01 | MI | BC PIN | OTHER | 1010612 | 01 | MI | MCLAREN | OTHER |