Basic Information
| Provider Information | |||||||||
| NPI: | 1952077679 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATAVA | ||||||||
| FirstName: | VICKI | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | MSN, APRN, AGCNS-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5625 EIGER RD STE 220 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787358982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128992028 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5625 EIGER RD STE 220 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787358982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128992028 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2021 | ||||||||
| LastUpdateDate: | 08/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SG0600X | 1051682 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Gerontology |
No ID Information.