Provider Demographics
NPI:1720025737
Name:MCKINLEY, MATTHEW W (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:W
Last Name:MCKINLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 HARPER DR
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3587
Mailing Address - Country:US
Mailing Address - Phone:505-823-8556
Mailing Address - Fax:505-823-8555
Practice Address - Street 1:1010 SPUCE ST
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-3456
Practice Address - Country:US
Practice Address - Phone:505-753-7111
Practice Address - Fax:505-753-4438
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM98-115207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPENDINGMedicaid
NMPENDINGMedicare UPIN
NMPENDINGMedicare ID - Type Unspecified