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General NPI Number Information
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NPI Number | 1417613985
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Entity Type | Individual
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Provider Name | IMAN MATTOX RN
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Gender | Male
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Dates
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Enumeration Date | 11/09/2021
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Last Update Date | 01/22/2025
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Provider Practice Location Address
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Address Line | 8080 E CENTRAL AVE STE 250
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City | WICHITA
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State | KS
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Zip | 67206
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Country | US
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Telephone | 316-686-7327
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Fax | 316-686-1557
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Provider Business Mailing Address
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Address Line | 8080 E CENTRAL AVE STE 250
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City | WICHITA
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State | KS
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Zip | 67206-2367
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Country | US
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Telephone | 316-686-7327
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Fax | 316-686-1557
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 95199822
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 558169
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License Number State | KS
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