Provider Demographics
NPI:1104805001
Name:MATTOX, PENN L (PA-C)
Entity type:Individual
Prefix:
First Name:PENN
Middle Name:L
Last Name:MATTOX
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 1ST AVENUE NORTH
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-8907
Mailing Address - Country:US
Mailing Address - Phone:727-822-3500
Mailing Address - Fax:727-822-3228
Practice Address - Street 1:4215 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-2206
Practice Address - Country:US
Practice Address - Phone:407-539-2000
Practice Address - Fax:407-398-0050
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3280363A00000X
FLPA380363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2920905 00Medicaid
FLE4034YOtherFL MCARE - QSS SOUTHEAST CLINICAL SERVICES
FLE4034YMedicare ID - Type UnspecifiedGROUP MEMBER NUMBER