Provider Demographics
NPI:1760021950
Name:MATA, TESSA DAVENPORT (PA-C)
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:DAVENPORT
Last Name:MATA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7017 A C SKINNER PKWY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6932
Mailing Address - Country:US
Mailing Address - Phone:904-520-6800
Mailing Address - Fax:
Practice Address - Street 1:7017 A C SKINNER PKWY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6932
Practice Address - Country:US
Practice Address - Phone:904-520-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-05
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112681363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant