Provider Demographics
NPI:1134143514
Name:MATUSOVICH, CHARLES S (FNP)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:MATUSOVICH
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CHABOT ST
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-4817
Mailing Address - Country:US
Mailing Address - Phone:207-857-9311
Mailing Address - Fax:207-857-9324
Practice Address - Street 1:2 CHABOT ST
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4817
Practice Address - Country:US
Practice Address - Phone:207-857-9311
Practice Address - Fax:207-857-9324
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER042849363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME287750099Medicaid
ME287750099Medicaid
MES85152Medicare UPIN