Provider Demographics
NPI:1760021885
Name:DEISE, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:DEISE
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 1:5550 N 16TH ST APT 175
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-2946
Mailing Address - Country:US
Mailing Address - Phone:602-430-3441
Mailing Address - Fax:
Practice Address - Street 1:3033 N CENTRAL AVE STE 700
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2806
Practice Address - Country:US
Practice Address - Phone:602-230-7373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ236093363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ000253Medicaid