Provider Demographics
NPI:1497772115
Name:MATTA, ELLEN L (CRNA)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:L
Last Name:MATTA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 E UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-8436
Mailing Address - Country:US
Mailing Address - Phone:480-892-8400
Mailing Address - Fax:480-892-1889
Practice Address - Street 1:2610 E UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-8436
Practice Address - Country:US
Practice Address - Phone:480-892-8400
Practice Address - Fax:480-892-1889
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA0158367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered