Provider Demographics
NPI:1578966602
Name:MATTA, NICOLAS JR
Entity Type:Individual
Prefix:MR
First Name:NICOLAS
Middle Name:
Last Name:MATTA
Suffix:JR
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 1:4120 158TH ST FL 3
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-2504
Mailing Address - Country:US
Mailing Address - Phone:347-526-1023
Mailing Address - Fax:
Practice Address - Street 1:41-20 158TH STREET 3 FLOOR
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358
Practice Address - Country:US
Practice Address - Phone:347-526-1023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY843232141174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist