Provider Demographics
NPI:1700187234
Name:MATTERA, JOSEPH ANTHONY
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:ANTHONY
Last Name:MATTERA
Suffix:
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 1:1366 W 7TH ST STE 4B
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3500
Mailing Address - Country:US
Mailing Address - Phone:131-054-7219
Mailing Address - Fax:
Practice Address - Street 1:1366 W 7TH ST STE 4B
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3500
Practice Address - Country:US
Practice Address - Phone:310-547-2197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-15
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21347363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant