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General NPI Number Information
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NPI Number | 1659169902
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Entity Type | Individual
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Provider Name | JARED MATTHEW STATEN MD
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Gender | Male
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Dates
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Enumeration Date | 04/28/2025
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Last Update Date | 04/28/2025
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Provider Practice Location Address
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Address Line | 590 MEDICAL CENTER RD
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City | FORT CAVAZOS
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State | TX
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Zip | 76544-5060
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Country | US
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Telephone | 254-288-8000
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Fax |
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Provider Business Mailing Address
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Address Line | 1441 N 64TH ST
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City | WAUWATOSA
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State | WI
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Zip | 53213-2931
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Country | US
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Telephone | 505-814-9471
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Fax |
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | BP10091432
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License Number State | TX
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