Provider Demographics
NPI:1659052793
Name:QUINTANA MATOS, TAY
Entity Type:Individual
Prefix:
First Name:TAY
Middle Name:
Last Name:QUINTANA MATOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 WOLF LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-1168
Mailing Address - Country:US
Mailing Address - Phone:702-374-5267
Mailing Address - Fax:702-232-1998
Practice Address - Street 1:2770 S MARYLAND PKWY STE 213A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-1565
Practice Address - Country:US
Practice Address - Phone:702-331-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant