Healthcare Provider Details

I. General information

NPI: 1770093650
Provider Name (Legal Business Name): MR. MATTHEW REGGIO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2017
Last Update Date: 05/30/2026
Certification Date: 05/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W 16TH ST
PUEBLO CO
81003-2745
US

IV. Provider business mailing address

1650 COCHRANE CIR
FORT CARSON CO
80913-4613
US

V. Phone/Fax

Practice location:
  • Phone: 719-584-4045
  • Fax:
Mailing address:
  • Phone: 719-526-7941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number5061101-8901
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN.0998420-CRNA
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: