Healthcare Provider Details

I. General information

NPI: 1740679075
Provider Name (Legal Business Name): ANDREA ALICE MATTSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2015
Last Update Date: 01/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 OLD AIRPORT RD NW 2318
ALBUQUERQUE NM
87114-9266
US

IV. Provider business mailing address

7900 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110-7513
US

V. Phone/Fax

Practice location:
  • Phone: 505-463-0723
  • Fax:
Mailing address:
  • Phone: 505-296-5565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA240
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: