Healthcare Provider Details

I. General information

NPI: 1700249133
Provider Name (Legal Business Name): MATTHEW WHARTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2016
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC 10 5600 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-4107
  • Fax:
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number55073
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD2021-0620
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: