Provider Demographics
NPI:1568143105
Name:MATYJASZEK, JEREMY DENIS
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DENIS
Last Name:MATYJASZEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1554 SURGEONS DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4631
Mailing Address - Country:US
Mailing Address - Phone:850-219-6800
Mailing Address - Fax:
Practice Address - Street 1:1554 SURGEONS DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4631
Practice Address - Country:US
Practice Address - Phone:850-219-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9276216163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty