Provider Demographics
NPI:1497474324
Name:MAYO, MATTHEW RIVERA
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RIVERA
Last Name:MAYO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 DARLENE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-1622
Mailing Address - Country:US
Mailing Address - Phone:650-418-0061
Mailing Address - Fax:
Practice Address - Street 1:2990 SAINT CLOUD DR
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-1748
Practice Address - Country:US
Practice Address - Phone:650-952-7778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95241913163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAY6259323OtherDMV