Healthcare Provider Details

I. General information

NPI: 1114487881
Provider Name (Legal Business Name): MICHAEL TODD MATHISEN APRN, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MICHAEL TODD MATHISEN APRN, PMHNP-BC

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4270 S DECATUR BLVD STE B6
LAS VEGAS NV
89103-6802
US

IV. Provider business mailing address

7171 ALMERTA AVE
LAS VEGAS NV
89178-8032
US

V. Phone/Fax

Practice location:
  • Phone: 702-485-2100
  • Fax: 702-902-2466
Mailing address:
  • Phone: 610-883-2862
  • Fax: 702-902-8466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number818912
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: