Healthcare Provider Details

I. General information

NPI: 1376561977
Provider Name (Legal Business Name): TRAVIS J MATTERN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 BROADWAY
FARGO ND
58122-0001
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-6259
  • Fax: 701-234-7334
Mailing address:
  • Phone: 605-328-9419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR27857
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1617
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: