Provider Demographics
NPI:1265415525
Name:MATTOS, NATALIE ANGELE (PA)
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:ANGELE
Last Name:MATTOS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2906
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95381-2906
Mailing Address - Country:US
Mailing Address - Phone:209-892-3111
Mailing Address - Fax:209-892-3112
Practice Address - Street 1:1114 6TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-2203
Practice Address - Country:US
Practice Address - Phone:209-576-2845
Practice Address - Fax:209-236-1290
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18095363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1069551OtherNCCPA CERT #
CA1069551OtherNCCPA CERT #
CAMM1312557OtherDEA CERT