Provider Demographics
NPI:1225463458
Name:MAA, MATTHEW GENE (MSN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GENE
Last Name:MAA
Suffix:
Gender:M
Credentials:MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E UNIVERSITY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6821
Mailing Address - Country:US
Mailing Address - Phone:877-800-5722
Mailing Address - Fax:512-869-2940
Practice Address - Street 1:1221 W BEN WHITE BLVD
Practice Address - Street 2:SUITE B300
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7192
Practice Address - Country:US
Practice Address - Phone:512-524-9293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP124012363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3317794-01Medicaid