Provider Demographics
NPI:1518601020
Name:MATA, PENNY ANGEL (MEDICAL ASSISTANT)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:ANGEL
Last Name:MATA
Suffix:
Gender:F
Credentials:MEDICAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4521 THOMAS JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-5100
Mailing Address - Country:US
Mailing Address - Phone:208-454-4820
Mailing Address - Fax:208-454-4859
Practice Address - Street 1:4521 THOMAS JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5100
Practice Address - Country:US
Practice Address - Phone:208-454-4820
Practice Address - Fax:208-454-4859
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist