Provider Demographics
NPI:1477062073
Name:MATTSON, MEGHAN
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:MATTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11901 4TH ST N APT 9105
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1739
Mailing Address - Country:US
Mailing Address - Phone:317-626-6691
Mailing Address - Fax:
Practice Address - Street 1:1200 7TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1300
Practice Address - Country:US
Practice Address - Phone:727-825-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9338712367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered