Provider Demographics
NPI:1316232135
Name:MATTA, JATIN R (PA-C, MPAS)
Entity type:Individual
Prefix:MR
First Name:JATIN
Middle Name:R
Last Name:MATTA
Suffix:
Gender:M
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16831 HARBOUR TOWN DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20905-4021
Mailing Address - Country:US
Mailing Address - Phone:301-476-9226
Mailing Address - Fax:
Practice Address - Street 1:1450 MERCANTILE LN
Practice Address - Street 2:SUITE 217
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5376
Practice Address - Country:US
Practice Address - Phone:301-583-7770
Practice Address - Fax:301-583-9414
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002229363A00000X
DCPA30146363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant