Provider Demographics
NPI:1356885198
Name:STINE, MATTHEW (CRNA)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:STINE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:165 NATCHEZ TRACE AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7940
Mailing Address - Country:US
Mailing Address - Phone:270-393-1912
Mailing Address - Fax:270-393-1913
Practice Address - Street 1:250 PARK ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1760
Practice Address - Country:US
Practice Address - Phone:270-393-1912
Practice Address - Fax:270-393-1913
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY3010955367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered