Provider Demographics
NPI:1457306870
Name:MATTISE, DOROTHY L (CRNA)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:L
Last Name:MATTISE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4268
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4268
Mailing Address - Country:US
Mailing Address - Phone:503-372-2740
Mailing Address - Fax:503-372-2754
Practice Address - Street 1:1055 N CURTIS RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1352
Practice Address - Country:US
Practice Address - Phone:208-367-6416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN7765163W00000X
IDRNA120367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004378300Medicaid
ID004378300Medicaid