Provider Demographics
NPI:1841629441
Name:MATTHIESEN, STEVEN THOMAS
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:THOMAS
Last Name:MATTHIESEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50820 SUMMIT HILL CT
Mailing Address - Street 2:SHADOWFAX ANESTHESIA
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-9720
Mailing Address - Country:US
Mailing Address - Phone:312-415-1137
Mailing Address - Fax:
Practice Address - Street 1:50820 SUMMIT HILL CT
Practice Address - Street 2:SHADOWFAX ANESTHESIA
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-9720
Practice Address - Country:US
Practice Address - Phone:312-415-1137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2015-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28212067A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered