Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | MD.202680 | LA |
N | 207N00000X | Dermatologist | N3169 | TX |
N | 207ND0900X | Dermatopathologist | MD.202680 | LA |
N | 207ND0900X | Dermatopathologist | N3169 | TX |
NPI | 1528259710 |
---|---|
Provider Name | Dr. Ryan Joseph Matherne |
First Address | Mathews, LA 70375-2025 |
Second Address | Thibodaux, LA 70301-5014 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/08/2007 |
Last Update Date | 09/08/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1500615 | (05) | LA |
5C904 | MEDICARE GROUP PIN (01) | LA |