Provider Demographics
NPI:1740884618
Name:MATEOS, JONAH MICAH
Entity type:Individual
Prefix:
First Name:JONAH
Middle Name:MICAH
Last Name:MATEOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 RIVER RD APT 2C
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-1347
Mailing Address - Country:US
Mailing Address - Phone:202-375-1890
Mailing Address - Fax:
Practice Address - Street 1:1150 RIVER RD APT 2C
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:07020-1347
Practice Address - Country:US
Practice Address - Phone:202-375-1890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY787603-01163WD1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD1100XNursing Service ProvidersRegistered NurseDialysis, Peritoneal