Healthcare Provider Details

I. General information

NPI: 1669833018
Provider Name (Legal Business Name): SARA JEAN MATHEWS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 D L INGRAM AVE W
CANNON AFB NM
88103-5103
US

IV. Provider business mailing address

208 D L INGRAM AVE W
CANNON AFB NM
88103-5103
US

V. Phone/Fax

Practice location:
  • Phone: 575-265-2411
  • Fax: 575-784-6329
Mailing address:
  • Phone:
  • Fax: 575-784-6329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number30237
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: