Provider Demographics
NPI:1497204119
Name:MATARUKA, ANNA TATIRA (FNP)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:TATIRA
Last Name:MATARUKA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1147 EBENEZER RD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-2355
Mailing Address - Country:US
Mailing Address - Phone:803-329-6648
Mailing Address - Fax:803-985-4134
Practice Address - Street 1:1147 EBENEZER RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2355
Practice Address - Country:US
Practice Address - Phone:803-329-6648
Practice Address - Fax:803-985-4134
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5014395363LF0000X
SC20481363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily