Healthcare Provider Details

I. General information

NPI: 1558096453
Provider Name (Legal Business Name): MATTHEW RAYMOND HASELTON FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2022
Last Update Date: 07/24/2022
Certification Date: 07/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 MANGROVE AVE
CHICO CA
95926-3509
US

IV. Provider business mailing address

100 FAIRGATE LN
CHICO CA
95926-7793
US

V. Phone/Fax

Practice location:
  • Phone: 530-345-0064
  • Fax:
Mailing address:
  • Phone: 925-487-8572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95021784
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: