Provider Demographics
NPI:1861772295
Name:JARDINIANO, MATIYAGA RAMIREZ (PA-C)
Entity type:Individual
Prefix:MR
First Name:MATIYAGA
Middle Name:RAMIREZ
Last Name:JARDINIANO
Suffix:
Gender:M
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 1:4844 BERRYWOOD RD.
Mailing Address - Street 2:
Mailing Address - City:VA. BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-5871
Mailing Address - Country:US
Mailing Address - Phone:757-962-0778
Mailing Address - Fax:
Practice Address - Street 1:4844 BERRYWOOD RD.
Practice Address - Street 2:
Practice Address - City:VA. BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-5871
Practice Address - Country:US
Practice Address - Phone:757-962-0778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840340363AM0700X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other