Provider Demographics
NPI:1578198982
Name:MCCARTY, MATTESON
Entity Type:Individual
Prefix:
First Name:MATTESON
Middle Name:
Last Name:MCCARTY
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 1:101 BUTTON BUSH CT
Mailing Address - Street 2:
Mailing Address - City:NOLANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76559-4738
Mailing Address - Country:US
Mailing Address - Phone:443-534-7994
Mailing Address - Fax:
Practice Address - Street 1:36065 SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5060
Practice Address - Country:US
Practice Address - Phone:254-618-8812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-05
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171000000XOther Service ProvidersMilitary Health Care Provider