Provider Demographics
NPI:1710569066
Name:MATLI, KATHARINE RAEDY (DO)
Entity Type:Individual
Prefix:
First Name:KATHARINE
Middle Name:RAEDY
Last Name:MATLI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KATHARINE
Other - Middle Name:
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1600 PROVIDENCE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76707-2261
Mailing Address - Country:US
Mailing Address - Phone:254-313-4400
Mailing Address - Fax:254-313-4549
Practice Address - Street 1:1600 PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76707-2261
Practice Address - Country:US
Practice Address - Phone:254-313-4400
Practice Address - Fax:254-313-4549
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10074691207Q00000X
TXT8274207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine