Healthcare Provider Details

I. General information

NPI: 1750833307
Provider Name (Legal Business Name): DEREK MATTESON R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2016
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 CAPE RD
MILFORD MA
01757-3292
US

IV. Provider business mailing address

100 BULLOCKS POINT AVE
RIVERSIDE RI
02915-5351
US

V. Phone/Fax

Practice location:
  • Phone: 800-853-2288
  • Fax:
Mailing address:
  • Phone: 401-437-1008
  • Fax: 401-433-3042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberRN53309
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2341300
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: