Healthcare Provider Details

I. General information

NPI: 1932798048
Provider Name (Legal Business Name): MATTHEW OTHMER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2021
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 EDISON WAY
RENO NV
89502-4117
US

IV. Provider business mailing address

450 EDISON WAY
RENO NV
89502-4117
US

V. Phone/Fax

Practice location:
  • Phone: 775-858-5700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number75934
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: