Healthcare Provider Details

I. General information

NPI: 1639852734
Provider Name (Legal Business Name): MATTHEW CONTRERAS RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 BROADWAY
SAN DIEGO CA
92101-5710
US

IV. Provider business mailing address

PO BOX 421141
SAN DIEGO CA
92142-1141
US

V. Phone/Fax

Practice location:
  • Phone: 619-276-8112
  • Fax:
Mailing address:
  • Phone: 619-692-8232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95345517
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: