Healthcare Provider Details

I. General information

NPI: 1013316488
Provider Name (Legal Business Name): MAKI MATSUMURA NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 TREAT BLVD STE 250A
WALNUT CREEK CA
94597-2168
US

IV. Provider business mailing address

1450 TREAT BLVD STE 300
WALNUT CREEK CA
94597-2168
US

V. Phone/Fax

Practice location:
  • Phone: 925-296-9740
  • Fax: 925-296-9062
Mailing address:
  • Phone: 925-952-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95001105
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95001105
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95001105
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: