Provider Demographics
NPI:1811980279
Name:MATTESON, MILTON ALLEN (PA-C)
Entity type:Individual
Prefix:MR
First Name:MILTON
Middle Name:ALLEN
Last Name:MATTESON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 SAINT MICHAELS DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7670
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:465 SAINT MICHAELS DR
Practice Address - Street 2:SUITE 110
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7670
Practice Address - Country:US
Practice Address - Phone:505-982-3534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2003-0039363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM34172866Medicaid