Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | DEN00203585 | CO |
Y | 213EG0000X | General Practice | DEN00203585 | CO |
NPI | 1003308099 |
---|---|
Provider Name | Matthew Tyler Wood |
First Address | Colorado Springs, CO 80906-4102 |
Second Address | Salida, CO 81201-9344 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/06/2018 |
Last Update Date | 12/09/2018 |