Provider Demographics
NPI:1932772399
Name:MATA, HEATHER D (FNP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:D
Last Name:MATA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3265 HILLCREST PARK DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7657
Mailing Address - Country:US
Mailing Address - Phone:541-494-9355
Mailing Address - Fax:
Practice Address - Street 1:3265 HILLCREST PARK DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7657
Practice Address - Country:US
Practice Address - Phone:541-494-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10002945363L00000X
OR201241027RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse