Healthcare Provider Details

I. General information

NPI: 1265793319
Provider Name (Legal Business Name): ANN M MATAKAS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANN MARIE MATAKAS

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 W COUNTRY CLUB RD
ROSWELL NM
88201-5211
US

IV. Provider business mailing address

603 W COUNTRY CLUB RD
ROSWELL NM
88201-5211
US

V. Phone/Fax

Practice location:
  • Phone: 575-624-4922
  • Fax: 575-624-4902
Mailing address:
  • Phone: 575-624-4922
  • Fax: 575-624-4902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number691067
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-03502
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: