Basic Information
| Provider Information | |||||||||
| NPI: | 1992123046 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATATOVA | ||||||||
| FirstName: | OLGA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10046 N METRO PKWY W | ||||||||
| Address2: | 115 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850511437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026745515 | ||||||||
| FaxNumber: | 6026743029 | ||||||||
| Practice Location | |||||||||
| Address1: | 10046 N METRO PKWY W | ||||||||
| Address2: | 115 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850511437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026745515 | ||||||||
| FaxNumber: | 6026743029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2014 | ||||||||
| LastUpdateDate: | 03/31/2016 | ||||||||
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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 | 363AM0700X | 5648 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.