Provider Demographics
NPI:1265193080
Name:MATAR, JUSTIN ALEXANDER
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ALEXANDER
Last Name:MATAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 BREEDERS CUP PL
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-5100
Mailing Address - Country:US
Mailing Address - Phone:949-836-7487
Mailing Address - Fax:
Practice Address - Street 1:11850 PIERCE ST STE 200
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-5184
Practice Address - Country:US
Practice Address - Phone:951-465-3664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95026056363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health