Provider Demographics
NPI:1861966418
Name:MATAVOSIAN, ALEX MATTHEW (PA-C)
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:MATTHEW
Last Name:MATAVOSIAN
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 1:10303 WHITEGATE AVE
Mailing Address - Street 2:
Mailing Address - City:SUNLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91040-3122
Mailing Address - Country:US
Mailing Address - Phone:865-804-5724
Mailing Address - Fax:
Practice Address - Street 1:558 SAINT CHARLES DR
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-3903
Practice Address - Country:US
Practice Address - Phone:805-449-8781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant