MEDICARE: RYAN MATSON R.N.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	R67509	NM

General Provider Information

NPI Number	:	1003215393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN MATSON R.N.

Provider Business Mailing Address
First Line	:	4806 CONSTITUTION AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-5806
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4806 CONSTITUTION AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-5806
Country	:	US
Telephone Number	:	832-656-7173
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2014
Last Update Date	:	08/22/2014

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