Provider Demographics
NPI:1164124178
Name:INDRA, MATTHEW K (RN)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:K
Last Name:INDRA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:K
Other - Last Name:CHILTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1832 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53726-4075
Mailing Address - Country:US
Mailing Address - Phone:608-358-4996
Mailing Address - Fax:
Practice Address - Street 1:1832 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53726-4075
Practice Address - Country:US
Practice Address - Phone:608-358-4996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI190545-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse