Provider Demographics
NPI:1083678429
Name:MATALA, MICHELE (ANP/FNP)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:MATALA
Suffix:
Gender:F
Credentials:ANP/FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 CENTER RD
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-1945
Mailing Address - Country:US
Mailing Address - Phone:716-677-4178
Mailing Address - Fax:716-677-4470
Practice Address - Street 1:290 CENTER RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-1945
Practice Address - Country:US
Practice Address - Phone:716-677-4178
Practice Address - Fax:716-677-4470
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302546-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner