Basic Information
Provider Information | |||||||||
NPI: | 1184958092 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MATTESON | ||||||||
FirstName: | CORA | ||||||||
MiddleName: | ROSE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHYSICIAN ASSISTANT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LININGER | ||||||||
OtherFirstName: | CORA | ||||||||
OtherMiddleName: | ROSE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 10900 W 44TH AVE UNIT 200 | ||||||||
Address2: |   | ||||||||
City: | WHEAT RIDGE | ||||||||
State: | CO | ||||||||
PostalCode: | 800332742 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3039231239 | ||||||||
FaxNumber: | 3032844082 | ||||||||
Practice Location | |||||||||
Address1: | 12250 E ILIFF AVE | ||||||||
Address2: | #300 | ||||||||
City: | AURORA | ||||||||
State: | CO | ||||||||
PostalCode: | 800146318 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033064321 | ||||||||
FaxNumber: | 7205241551 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/24/2009 | ||||||||
LastUpdateDate: | 09/18/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2825 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 23883871 | 05 | CO |   | MEDICAID |