Provider Demographics
NPI:1942727722
Name:MATOUKA, ALISA ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:ANNE
Last Name:MATOUKA
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 1:4510 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-3516
Mailing Address - Country:US
Mailing Address - Phone:954-893-8900
Mailing Address - Fax:954-893-8992
Practice Address - Street 1:4510 SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-3516
Practice Address - Country:US
Practice Address - Phone:954-893-8900
Practice Address - Fax:954-893-8992
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100937363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical