Provider Demographics
NPI:1831666338
Name:MATLOCK, KAYANNA M (PA-C)
Entity Type:Individual
Prefix:
First Name:KAYANNA
Middle Name:M
Last Name:MATLOCK
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 1:852 DANENBERG DR
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-8517
Mailing Address - Country:US
Mailing Address - Phone:760-352-2257
Mailing Address - Fax:760-352-4579
Practice Address - Street 1:852 DANENBERG DR
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-8517
Practice Address - Country:US
Practice Address - Phone:760-352-2257
Practice Address - Fax:760-352-4579
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59202363A00000X
NVPA2078363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant