Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LP0200X | Nurse Practitioner - Pediatrics | 28160775 | IN |
N | 363LP0200X | Nurse Practitioner - Pediatrics | 6873536 | TX |
N | 363LP0200X | Nurse Practitioner - Pediatrics | 71003123 | IN |
Y | 363LP0200X | Nurse Practitioner - Pediatrics | AP121172 | TX |
NPI | 1033445416 |
---|---|
Provider Name | Johanna Matos |
First Address | San Antonio, TX 78229-3901 |
Second Address | San Antonio, TX 78229-3901 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/10/2009 |
Last Update Date | 18/05/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
080462703 | (05) | TX |
200966730 | (05) | IN |
327258503 | (05) | TX |
327258504 | CSHCN (01) | TX |
567581YK00 | (02) | TX |