Basic Information
| Provider Information | |||||||||
| NPI: | 1578874863 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHIE | ||||||||
| FirstName: | MORGAN | ||||||||
| MiddleName: | FULLMER | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 41150 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852741150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804252162 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2421 E SOUTHERN AVE | ||||||||
| Address2: | STE 7 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852827612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022628900 | ||||||||
| FaxNumber: | 6022628890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2010 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 006380 | AZ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.