Provider Demographics
NPI:1265793319
Name:MATAKAS, ANN M (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:ANN
Middle Name:M
Last Name:MATAKAS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:MARIE
Other - Last Name:MATAKAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:603 W COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5211
Mailing Address - Country:US
Mailing Address - Phone:575-624-4922
Mailing Address - Fax:575-624-4902
Practice Address - Street 1:603 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5211
Practice Address - Country:US
Practice Address - Phone:575-624-4922
Practice Address - Fax:575-624-4902
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX691067363LF0000X
NMCNP-03502363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1265793319OtherBCBS NM
NM79679021Medicaid
NM634354YYH0OtherMEDICARE