MEDICARE: MR. MILTON ALLEN MATTESON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA2003-0039	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811980279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MILTON ALLEN MATTESON PA-C

Provider Business Mailing Address
First Line	:	465 SAINT MICHAELS DR
Second Line	:	SUITE 110
City	:	SANTA FE
State	:	NM
Zip	:	87505-7670
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	465 SAINT MICHAELS DR
Second Line	:	SUITE 110
City	:	SANTA FE
State	:	NM
Zip	:	87505-7670
Country	:	US
Telephone Number	:	505-982-3534
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2005
Last Update Date	:	05/25/2016

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Directions to “ MR. MILTON ALLEN MATTESON PA-C” Practice Location

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