Healthcare Provider Details

I. General information

NPI: 1629514245
Provider Name (Legal Business Name): MATTHEW NAGTALON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2017
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E VALENCIA MESA DR
FULLERTON CA
92835-3809
US

IV. Provider business mailing address

783 GATUN ST
SAN PEDRO CA
90731-1339
US

V. Phone/Fax

Practice location:
  • Phone: 714-871-3280
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95005723
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number95005723
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: