Provider Demographics
NPI:1912685686
Name:MATTISON PATHOLOGY, L.L.P.
Entity Type:Organization
Organization Name:MATTISON PATHOLOGY, L.L.P.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-232-9924
Mailing Address - Street 1:6221 RIVERSIDE DR STE 119
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-3515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 RENAISSANCE BLVD STE L100
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3023
Practice Address - Country:US
Practice Address - Phone:877-232-9924
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty