Healthcare Provider Details

I. General information

NPI: 1386976397
Provider Name (Legal Business Name): MATTHEW MYERS PETERS CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2010
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 9TH AVE
T OR C NM
87901-1954
US

IV. Provider business mailing address

PO BOX 2267
SANTA FE NM
87504-2267
US

V. Phone/Fax

Practice location:
  • Phone: 575-894-3221
  • Fax: 575-894-4999
Mailing address:
  • Phone: 540-222-0869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN1025634
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number0024147900
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number61497
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: