Provider Demographics
NPI:1720033764
Name:MATTINGLY, JAMES LEE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:LEE
Last Name:MATTINGLY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 W 168TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3720
Mailing Address - Country:US
Mailing Address - Phone:212-305-9878
Mailing Address - Fax:212-305-8980
Practice Address - Street 1:5141 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-1159
Practice Address - Country:US
Practice Address - Phone:212-305-9876
Practice Address - Fax:212-305-8980
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO126000367500000X
NY635864367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO430069965OtherMO RR MEDICARE NUMBER
MO28264022OtherMO BCBS NUMBER
MO915831309Medicaid
MO100388350BMedicaid
MOJ22A518Medicare ID - Type UnspecifiedMO MEDICARE NUMBER