Provider Demographics
NPI:1316427479
Name:MATATOVA, ADELINA (PA-C)
Entity type:Individual
Prefix:
First Name:ADELINA
Middle Name:
Last Name:MATATOVA
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 1:7300 RANCH ROAD 2222, BUILDING 1, STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730
Mailing Address - Country:US
Mailing Address - Phone:512-628-0465
Mailing Address - Fax:
Practice Address - Street 1:2 N CENTRAL AVE STE 120
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-2972
Practice Address - Country:US
Practice Address - Phone:602-296-4060
Practice Address - Fax:602-296-4146
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7629170001332B00000X
AZ7034950001332B00000X
AZ7047150001332B00000X
AZ7209350001332B00000X
AZ7057360001332B00000X
AZ7045160001332B00000X
AZ7046960001332B00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies