Provider Demographics
NPI:1104600428
Name:MITCHELL, MATTHEW (NP)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30300 CABRILLO AVE
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-2427
Mailing Address - Country:US
Mailing Address - Phone:508-979-0407
Mailing Address - Fax:
Practice Address - Street 1:31573 RANCHO PUEBLO RD STE 210
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-4853
Practice Address - Country:US
Practice Address - Phone:508-979-0407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95026630363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care