Provider Demographics
NPI:1114487881
Name:MATHISEN, MICHAEL TODD (APRN, PMHNP-BC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:TODD
Last Name:MATHISEN
Suffix:
Gender:M
Credentials:APRN, PMHNP-BC
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:TODD
Other - Last Name:MATHISEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN, PMHNP-BC
Mailing Address - Street 1:7171 ALMERTA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89178-8032
Mailing Address - Country:US
Mailing Address - Phone:610-883-2862
Mailing Address - Fax:702-902-8466
Practice Address - Street 1:4270 S DECATUR BLVD STE B6
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-6802
Practice Address - Country:US
Practice Address - Phone:702-485-2100
Practice Address - Fax:702-902-2466
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV818912363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty