Provider Demographics
NPI:1235678954
Name:MATSON, PAUL
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:MATSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 MADISON AVE STE 352
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4458
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1400 MADISON AVE STE 352
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4458
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-14
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6103363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health