Provider Demographics
NPI:1891148052
Name:MATSON, STEPHEN (CRNA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:MATSON
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 1:21 BEACON ST
Mailing Address - Street 2:APT 1T
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02108-2804
Mailing Address - Country:US
Mailing Address - Phone:989-859-1054
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2307471367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered