Provider Demographics
NPI:1578145447
Name:MATTES, CHEYENNE (MD)
Entity Type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:
Last Name:MATTES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11937 US HIGHWAY 271
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75708-3154
Mailing Address - Country:US
Mailing Address - Phone:903-877-7777
Mailing Address - Fax:
Practice Address - Street 1:11937 US HIGHWAY 271
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75708-3154
Practice Address - Country:US
Practice Address - Phone:903-877-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10075201390200000X
TNU1719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program