Provider Demographics
NPI:1033365291
Name:MAUPIN, MATHEW J (CRNA)
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:J
Last Name:MAUPIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 N KNOXVILLE AVE STE 416
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5021
Mailing Address - Country:US
Mailing Address - Phone:309-692-7246
Mailing Address - Fax:309-692-7226
Practice Address - Street 1:5401 N. KNOXVILLE SUITE 416
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61528
Practice Address - Country:US
Practice Address - Phone:309-692-7246
Practice Address - Fax:309-692-7226
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007157367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered