Provider Demographics
NPI:1184462772
Name:MASTAW, PAYTON LEIGH
Entity type:Individual
Prefix:
First Name:PAYTON
Middle Name:LEIGH
Last Name:MASTAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 CLUBHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:KINCHELOE
Mailing Address - State:MI
Mailing Address - Zip Code:49788-1412
Mailing Address - Country:US
Mailing Address - Phone:906-440-7781
Mailing Address - Fax:
Practice Address - Street 1:14 CLUBHOUSE DR
Practice Address - Street 2:
Practice Address - City:KINCHELOE
Practice Address - State:MI
Practice Address - Zip Code:49788-1412
Practice Address - Country:US
Practice Address - Phone:906-440-7781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty