MEDICARE: LATWANA MATTHEW

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	363L00000X	Nurse Practitioner	AP134054	TX
2	363L00000X	Nurse Practitioner	AP09035	LA
3	363LF0000X	Family Nurse Practitioner	09035	LA
4	363LF0000X	Family Nurse Practitioner	AP09035	LA

General Provider Information

NPI Number	:	1902349848
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATWANA MATTHEW

Provider Business Mailing Address
First Line	:	1640 BREAZEALE SPRINGS ST
Second Line	:
City	:	NATCHITOCHES
State	:	LA
Zip	:	71457-4278
Country	:	US
Telephone Number	:	318-352-9299
Fax Number	:

Provider Business Practice Location Address
First Line	:	1640 BREAZEALE SPRINGS ST
Second Line	:
City	:	NATCHITOCHES
State	:	LA
Zip	:	71457-4278
Country	:	US
Telephone Number	:	318-352-9299
Fax Number	:

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

Provider Enumeration Date	:	11/27/2016
Last Update Date	:	03/21/2023

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