Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | G29338 | CA |
N | 2080P0202X | Pediatric Cardiologist | G29338 | CA |
NPI | 1043381809 |
---|---|
Provider Name | James Wallace Mathewson |
First Address | Flagstaff, AZ 86004-7216 |
Second Address | Flagstaff, AZ 86001-3134 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G293380 | (05) | CA |
A44018 | (02) | CA |