Provider Demographics
NPI:1578906061
Name:MATAYA, TINA L (NTP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:L
Last Name:MATAYA
Suffix:
Gender:F
Credentials:NTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29061 SE HIGHWAY 224
Mailing Address - Street 2:
Mailing Address - City:EAGLE CREEK
Mailing Address - State:OR
Mailing Address - Zip Code:97022-9719
Mailing Address - Country:US
Mailing Address - Phone:503-303-8153
Mailing Address - Fax:
Practice Address - Street 1:115 W GLOUCESTER ST
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-2032
Practice Address - Country:US
Practice Address - Phone:503-303-8153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-15
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist