Provider Demographics
NPI:1962499293
Name:MATTINGLY, MARK SEAN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:SEAN
Last Name:MATTINGLY
Suffix:
Gender:M
Credentials:CRNA
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Mailing Address - Street 1:1500 MARKET ST
Mailing Address - Street 2:24TH FLOOR-WEST TOWER
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-2100
Mailing Address - Country:US
Mailing Address - Phone:215-255-3828
Mailing Address - Fax:215-255-3577
Practice Address - Street 1:230 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-1121
Practice Address - Country:US
Practice Address - Phone:215-762-7922
Practice Address - Fax:215-762-8656
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN560464367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP765477Medicare UPIN
PA089109Medicare PIN