Provider Demographics
NPI:1659597599
Name:MATA, ROXANA (PA-C)
Entity Type:Individual
Prefix:
First Name:ROXANA
Middle Name:
Last Name:MATA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 LAVACA ST # 35
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-1634
Mailing Address - Country:US
Mailing Address - Phone:512-566-4233
Mailing Address - Fax:
Practice Address - Street 1:814 GRAFTON AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94112-2222
Practice Address - Country:US
Practice Address - Phone:512-566-4233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15670363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant