Provider Demographics
NPI:1497393706
Name:MATIAS, JOSE LUIS SR (PA)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:LUIS
Last Name:MATIAS
Suffix:SR
Gender:M
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:CALLE EDEN
Mailing Address - Street 2:X26 GLENVIEW GARDEN
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00730
Mailing Address - Country:US
Mailing Address - Phone:787-813-9094
Mailing Address - Fax:
Practice Address - Street 1:CALLE EDEN
Practice Address - Street 2:X26 GLENVIEW GARDEN
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00730
Practice Address - Country:US
Practice Address - Phone:787-813-9094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR225363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical