Provider Demographics
NPI:1801464623
Name:MATSHOBA, MARY NATSAI (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:NATSAI
Last Name:MATSHOBA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2484 WYNSLEY WAY
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-3767
Mailing Address - Country:US
Mailing Address - Phone:248-894-6784
Mailing Address - Fax:
Practice Address - Street 1:2484 WYNSLEY WAY
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-3767
Practice Address - Country:US
Practice Address - Phone:248-894-6784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAG04210053363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology