Provider Demographics
NPI:1174052229
Name:MATOS-MORENO, EDINSON ANTONIO (SA-C)
Entity type:Individual
Prefix:
First Name:EDINSON
Middle Name:ANTONIO
Last Name:MATOS-MORENO
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 SW 148TH AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33325-3080
Mailing Address - Country:US
Mailing Address - Phone:954-801-8559
Mailing Address - Fax:
Practice Address - Street 1:705 SW 148TH AVE APT 202
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33325
Practice Address - Country:US
Practice Address - Phone:954-801-8559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
FL14-481246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant