Provider Demographics
NPI:1275860868
Name:MATAELE, KARLA (PA)
Entity Type:Individual
Prefix:
First Name:KARLA
Middle Name:
Last Name:MATAELE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KARLA
Other - Middle Name:
Other - Last Name:KANONGATAA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6195 LUSK BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3715
Mailing Address - Country:US
Mailing Address - Phone:858-859-1188
Mailing Address - Fax:
Practice Address - Street 1:6195 LUSK BLVD STE 250
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3715
Practice Address - Country:US
Practice Address - Phone:858-859-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7495099-1206363AM0700X
CAPA21532363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT7495099-1206OtherSTATE LICENSE
CAPA21532OtherDEPARMENT OF CONSUMER AFFAIRS PHYSCIAN ASSISTANT BOARD