Basic Information
| Provider Information | |||||||||
| NPI: | 1154321420 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATZKE | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5400 FRANTZ RD 250 | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430166102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145446161 | ||||||||
| FaxNumber: | 6145446370 | ||||||||
| Practice Location | |||||||||
| Address1: | 561 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DELAWARE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430151410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406151000 | ||||||||
| FaxNumber: | 7406152565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 02/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | CNP.14059 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 14059 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0082732 | 05 | OH | MEDICAID | H185562 | 01 | OH | MEDICARE | OTHER |