Provider Demographics
NPI:1952077679
Name:MATAVA, VICKI JO (MSN, APRN, AGCNS-BC)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:JO
Last Name:MATAVA
Suffix:
Gender:F
Credentials:MSN, APRN, AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5625 EIGER RD STE 220
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8982
Mailing Address - Country:US
Mailing Address - Phone:512-899-2028
Mailing Address - Fax:
Practice Address - Street 1:5625 EIGER RD STE 220
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-8982
Practice Address - Country:US
Practice Address - Phone:512-899-2028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-22
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1051682364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontologyGroup - Single Specialty