Healthcare Provider Details

I. General information

NPI: 1114035433
Provider Name (Legal Business Name): MATTHEW MILDONIAN NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MARTHA JEFFERSON DR MB# G287
CHARLOTTESVILLE VA
22911-4668
US

IV. Provider business mailing address

PO BOX 79777
BALTIMORE MD
21279-0777
US

V. Phone/Fax

Practice location:
  • Phone: 434-654-8390
  • Fax: 434-654-8391
Mailing address:
  • Phone: 434-654-7794
  • Fax: 434-654-7752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024165779
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: