Healthcare Provider Details

I. General information

NPI: 1487725594
Provider Name (Legal Business Name): EDWARD S MATTHEWS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2006
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SERENO DR
VALLEJO CA
94589-2441
US

IV. Provider business mailing address

207 RADNOR CT
BENICIA CA
94510-1516
US

V. Phone/Fax

Practice location:
  • Phone: 707-651-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN545458
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: