Provider Demographics
NPI:1417496522
Name:MATOS, LUMARY (PA)
Entity Type:Individual
Prefix:
First Name:LUMARY
Middle Name:
Last Name:MATOS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 W OAK ST STE 103
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4973
Mailing Address - Country:US
Mailing Address - Phone:407-931-0444
Mailing Address - Fax:407-962-4446
Practice Address - Street 1:931 W OAK ST STE 103
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4973
Practice Address - Country:US
Practice Address - Phone:407-931-0444
Practice Address - Fax:407-962-4446
Is Sole Proprietor?:No
Enumeration Date:2017-02-22
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110209363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical