Provider Demographics
NPI:1356633945
Name:MATTESON, GINA LOUISE (MD)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:LOUISE
Last Name:MATTESON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 HIGHPARK DR
Mailing Address - Street 2:
Mailing Address - City:ANACONDA
Mailing Address - State:MT
Mailing Address - Zip Code:59711-6130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7308 FLEMING AVE
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1829
Practice Address - Country:US
Practice Address - Phone:412-605-4866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP100405572084P0800X
TXP52892084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry