Provider Demographics
NPI:1639871247
Name:MATA, JOHN MICHAEL BLANCO (NP)
Entity Type:Individual
Prefix:
First Name:JOHN MICHAEL
Middle Name:BLANCO
Last Name:MATA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 522
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:AZ
Mailing Address - Zip Code:86329-0522
Mailing Address - Country:US
Mailing Address - Phone:708-248-0049
Mailing Address - Fax:
Practice Address - Street 1:3250 GATEWAY BLVD STE 112
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-6856
Practice Address - Country:US
Practice Address - Phone:708-248-0049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ267971363LA2100X, 363LA2200X, 363LC0200X, 363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology