Provider Demographics
NPI:1013663343
Name:MATA, CHARLIE (CRNA)
Entity type:Individual
Prefix:
First Name:CHARLIE
Middle Name:
Last Name:MATA
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 HOGBACK RD
Mailing Address - Street 2:SUITE 5A
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105
Mailing Address - Country:US
Mailing Address - Phone:734-263-2414
Mailing Address - Fax:734-773-3471
Practice Address - Street 1:4725 N. FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4603
Practice Address - Country:US
Practice Address - Phone:954-771-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-24
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9347349163W00000X
FLAPRN11033142367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL124611300Medicaid