Provider Demographics
NPI:1760137178
Name:MATOS, RAFAEL (APRN)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:MATOS
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 NW 107TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33172-2746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6726 HANLEY RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-4739
Practice Address - Country:US
Practice Address - Phone:813-284-7903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11018042363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily