Provider Demographics
NPI:1407949985
Name:MATTA, KIMBERLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MATTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:BREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:929 GESSNER RD STE 2200
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-2583
Mailing Address - Country:US
Mailing Address - Phone:713-337-5277
Mailing Address - Fax:
Practice Address - Street 1:18400 KATY FWY
Practice Address - Street 2:SUITE 530
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77094-1286
Practice Address - Country:US
Practice Address - Phone:281-717-4003
Practice Address - Fax:281-206-7597
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08479363A00000X
CO2204363A00000X
TXPA8479363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX322814001Medicaid
TX297355YQCCMedicare PIN