Provider Demographics
NPI:1962075622
Name:MATOS, MIRCIA (RN)
Entity type:Individual
Prefix:
First Name:MIRCIA
Middle Name:
Last Name:MATOS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 E 46TH ST APT 20
Mailing Address - Street 2:
Mailing Address - City:N LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72117-1966
Mailing Address - Country:US
Mailing Address - Phone:501-259-3271
Mailing Address - Fax:
Practice Address - Street 1:4405 E 46TH ST APT 20
Practice Address - Street 2:
Practice Address - City:N LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-1966
Practice Address - Country:US
Practice Address - Phone:501-259-3271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR092350163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse