Healthcare Provider Details

I. General information

NPI: 1629450911
Provider Name (Legal Business Name): MATTHEW SAXSMA FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2015
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N 1ST ST
SPRINGFIELD IL
62781-0001
US

IV. Provider business mailing address

701 N 1ST ST
SPRINGFIELD IL
62781-9113
US

V. Phone/Fax

Practice location:
  • Phone: 217-188-3156
  • Fax:
Mailing address:
  • Phone: 217-788-3156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209012893
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: