Healthcare Provider Details

I. General information

NPI: 1164073284
Provider Name (Legal Business Name): MATTHEW ROBERT SIMONETTI CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 DELBON AVE
TURLOCK CA
95382-2016
US

IV. Provider business mailing address

4434 SYDNEY ROSE CT SE
OLYMPIA WA
98501-6016
US

V. Phone/Fax

Practice location:
  • Phone: 209-667-4200
  • Fax:
Mailing address:
  • Phone: 360-791-9162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95200501
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: