Provider Demographics
NPI:1780606798
Name:MATIJAS, CHRISTINE ANN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:ANN
Last Name:MATIJAS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:MRS
Other - First Name:CHRISTINE
Other - Middle Name:GRISWOLD
Other - Last Name:MATIJAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:60 MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:PORT BYRON
Mailing Address - State:NY
Mailing Address - Zip Code:13140
Mailing Address - Country:US
Mailing Address - Phone:315-497-1013
Mailing Address - Fax:
Practice Address - Street 1:60 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PORT BYRON
Practice Address - State:NY
Practice Address - Zip Code:13140
Practice Address - Country:US
Practice Address - Phone:315-776-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY331655363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01752616Medicaid
NY01752616Medicaid
S43796Medicare UPIN