Provider Demographics
NPI:1184958092
Name:MATTESON, CORA ROSE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:CORA
Middle Name:ROSE
Last Name:MATTESON
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:CORA
Other - Middle Name:ROSE
Other - Last Name:LININGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10900 W 44TH AVE UNIT 200
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-2742
Mailing Address - Country:US
Mailing Address - Phone:303-923-1239
Mailing Address - Fax:303-284-4082
Practice Address - Street 1:12250 E ILIFF AVE
Practice Address - Street 2:#300
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-6318
Practice Address - Country:US
Practice Address - Phone:303-306-4321
Practice Address - Fax:720-524-1551
Is Sole Proprietor?:No
Enumeration Date:2009-09-24
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2825363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO23883871Medicaid
CO23883871Medicaid