Healthcare Provider Details

I. General information

NPI: 1760752695
Provider Name (Legal Business Name): MATTHEW J MITCHELL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6250 US HIGHWAY 83
ABILENE TX
79606-5215
US

IV. Provider business mailing address

PO BOX 7909
LONGVIEW TX
75607-7909
US

V. Phone/Fax

Practice location:
  • Phone: 325-428-1000
  • Fax:
Mailing address:
  • Phone: 903-643-8869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number98827
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number744782
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: