Provider Demographics
NPI:1922027168
Name:MATTA, TANIA MILAD (MD)
Entity Type:Individual
Prefix:MRS
First Name:TANIA
Middle Name:MILAD
Last Name:MATTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 S ZINTEL WAY
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-942-2268
Practice Address - Street 1:3950 KEENE ROAD
Practice Address - Street 2:
Practice Address - City:WEST RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99353
Practice Address - Country:US
Practice Address - Phone:509-942-3130
Practice Address - Fax:509-628-8335
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010605932080A0000X
WAMD000485172080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8493512Medicaid
IN200527760Medicaid
IN200527760Medicaid
IN141081Medicare UPIN
IN220170BBMedicare ID - Type Unspecified