Provider Demographics
NPI:1508128158
Name:MATAMOROS, KATHILEE J
Entity Type:Individual
Prefix:
First Name:KATHILEE
Middle Name:J
Last Name:MATAMOROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHILEE
Other - Middle Name:J
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6820 NW 23RD ST
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-5217
Mailing Address - Country:US
Mailing Address - Phone:405-495-5154
Mailing Address - Fax:
Practice Address - Street 1:6820 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-5217
Practice Address - Country:US
Practice Address - Phone:405-495-5154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATLRN039071163W00000X
PASP012283363L00000X, 363LF0000X
OK90694363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200526530AMedicaid