Provider Demographics
NPI:1063594117
Name:MATA, FERNANDO U (PAC)
Entity type:Individual
Prefix:MR
First Name:FERNANDO
Middle Name:U
Last Name:MATA
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:FERNANDO
Other - Middle Name:ULLOA
Other - Last Name:MATA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:10200 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAMONT
Mailing Address - State:CA
Mailing Address - Zip Code:93241-1700
Mailing Address - Country:US
Mailing Address - Phone:661-845-1788
Mailing Address - Fax:661-845-1791
Practice Address - Street 1:10200 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAMONT
Practice Address - State:CA
Practice Address - Zip Code:93241-1700
Practice Address - Country:US
Practice Address - Phone:661-845-1788
Practice Address - Fax:661-845-1791
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12281363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA12281Medicaid