Provider Demographics
NPI:1093820763
Name:MATTISON PATHOLOGY, L.L.P.
Entity Type:Organization
Organization Name:MATTISON PATHOLOGY, L.L.P.
Other - Org Name:AVERO DIAGNOSTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOLGAMOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:806-687-7284
Mailing Address - Street 1:3560 MERIDIAN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1731
Mailing Address - Country:US
Mailing Address - Phone:360-734-2800
Mailing Address - Fax:360-734-3818
Practice Address - Street 1:4642 N LOOP 289 STE 205
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-2424
Practice Address - Country:US
Practice Address - Phone:360-543-6836
Practice Address - Fax:971-402-0065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207ZC0500X, 207ZP0102X, 207ZP0105X
TX45D1015603291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Multi-Specialty
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR177874709Medicaid
TX45D1069527OtherCLIA
TXL166OtherFIRSTCARE
TX45D1015603OtherCLIA
NM72922010Medicaid
TX7187034OtherCOLLEGE OF AMERICAN PATHOLOGISTS
TX7201511OtherCOLLEGE OF AMERICAN PATHOLOGISTS
TX0075KPOtherBLUE CROSS BLUE SHIELD
TX1646044-01Medicaid