Provider Demographics
NPI:1083141394
Name:MATA, NOHE (PTA)
Entity Type:Individual
Prefix:
First Name:NOHE
Middle Name:
Last Name:MATA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-5825
Mailing Address - Country:US
Mailing Address - Phone:208-570-0455
Mailing Address - Fax:
Practice Address - Street 1:4301 GARRITY BLVD STE 103
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-9222
Practice Address - Country:US
Practice Address - Phone:208-463-0700
Practice Address - Fax:208-463-0700
Is Sole Proprietor?:No
Enumeration Date:2017-05-17
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-5158225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant