Healthcare Provider Details

I. General information

NPI: 1255969564
Provider Name (Legal Business Name): NICHOLAS LOUIS DIMATTEO APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 N BECKLEY AVE
DALLAS TX
75203-1201
US

IV. Provider business mailing address

6451 BRENTWOOD STAIR RD STE 200
FORT WORTH TX
76112-3200
US

V. Phone/Fax

Practice location:
  • Phone: 817-909-4290
  • Fax:
Mailing address:
  • Phone: 817-496-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1008024
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: