Basic Information
Provider Information | |||||||||
NPI: | 1861911539 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MATINKO | ||||||||
FirstName: | PATRICK | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 565 COAL VALLEY RD | ||||||||
Address2: |   | ||||||||
City: | JEFFERSON HILLS | ||||||||
State: | PA | ||||||||
PostalCode: | 150253703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4124695000 | ||||||||
FaxNumber: | 4124697174 | ||||||||
Practice Location | |||||||||
Address1: | 565 COAL VALLEY ROAD | ||||||||
Address2: |   | ||||||||
City: | PITTSBURGH | ||||||||
State: | PA | ||||||||
PostalCode: | 152363703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4124695100 | ||||||||
FaxNumber: | 4128315663 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/14/2017 | ||||||||
LastUpdateDate: | 10/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN601308 | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | RN601308 | 01 | PA | RN LICENSE | OTHER |