Basic Information
| Provider Information | |||||||||
| NPI: | 1760426936 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATTE | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | WILLIAMS | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 427 HIGHWAY 51 N | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018336011 | ||||||||
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| Practice Location | |||||||||
| Address1: | 427 HWY 51 NORTH | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018337831 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 05/13/2015 | ||||||||
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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 | 207P00000X | R785369 | MS | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208M00000X | R785369 | MS | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 00122352 | 05 | MS | MEDICAID | R785369 | 01 | MS | MS LICENSE | OTHER |