Basic Information
| Provider Information | |||||||||
| NPI: | 1255659892 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATA | ||||||||
| FirstName: | GISELLE | ||||||||
| MiddleName: | ALICIA | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17360 BROOKHURST STREET | ||||||||
| Address2: | ATTN: CREDENTIALING DEPT. | ||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927083720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6572413592 | ||||||||
| FaxNumber: | 7146654614 | ||||||||
| Practice Location | |||||||||
| Address1: | 1212 W 17TH ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927063418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143772348 | ||||||||
| FaxNumber: | 7143772866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2010 | ||||||||
| LastUpdateDate: | 05/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP19537 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.