Provider Demographics
NPI:1588844351
Name:OTA, MATTHEW MIKIO (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:MIKIO
Last Name:OTA
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:2230 SW 19TH AVENUE RD
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-1391
Mailing Address - Country:US
Mailing Address - Phone:352-237-4133
Mailing Address - Fax:352-237-7728
Practice Address - Street 1:2135 SW 19TH AVENUE RD STE 103
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-7877
Practice Address - Country:US
Practice Address - Phone:352-237-4133
Practice Address - Fax:352-237-7728
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2019-11-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9107328363A00000X
HIAMD-309363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant