1891124970 NPI number — MOLLY ANNE MATTHEWS PAC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891124970 NPI number — MOLLY ANNE MATTHEWS PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTHEWS
Provider First Name:
MOLLY
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891124970
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2825 E BARNETT RD # MSS
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97504-8332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-789-4281
Provider Business Mailing Address Fax Number:
541-789-4806

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97504-8458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-789-5790
Provider Business Practice Location Address Fax Number:
541-789-5973
Provider Enumeration Date:
11/08/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA205662 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AM0700X , with the licence number: PA0003834 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA0003834 . This is a "COLORADO LICENSE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: PA205662 . This is a "OREGON MEDICAL BOARD" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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