Basic Information
| Provider Information | |||||||||
| NPI: | 1831666338 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATLOCK | ||||||||
| FirstName: | KAYANNA | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 852 DANENBERG DR | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922438517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603522257 | ||||||||
| FaxNumber: | 7603524579 | ||||||||
| Practice Location | |||||||||
| Address1: | 852 DANENBERG DR | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922438517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603522257 | ||||||||
| FaxNumber: | 7603524579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2018 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 59202 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA2078 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.