1093820763 NPI number — MATTISON PATHOLOGY, L.L.P.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093820763 NPI number — MATTISON PATHOLOGY, L.L.P.

Employer Identification Number (EIN):

Provider Organization Name:

MATTISON PATHOLOGY, L.L.P.

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

Provider Other Organization Name:

AVERO DIAGNOSTICS

Provider Other Organization Name Type Code:

3

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:

1093820763

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

04/04/2024

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

3560 MERIDIAN ST STE 101

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

BELLINGHAM

Provider Business Mailing Address State Name:

WA

Provider Business Mailing Address Postal Code:

98225-1731

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

360-734-2800

Provider Business Mailing Address Fax Number:

360-734-3818

Provider First Line Business Practice Location Address:

4642 N LOOP 289 STE 205

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

LUBBOCK

Provider Business Practice Location Address State Name:

TX

Provider Business Practice Location Address Postal Code:

79416-2424

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

360-543-6836

Provider Business Practice Location Address Fax Number:

971-402-0065

Provider Enumeration Date:

08/20/2006

Authorized Official Last Name:

WOLGAMOT

Authorized Official First Name:

GREGORY

Authorized Official Middle Name:

M

Authorized Official Title or Position:

M.D.

Authorized Official Telephone Number:

806-687-7284

• Taxonomy code: 207ZC0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 207ZP0105X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 291U00000X , with the licence number: 45D1015603 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 177874709 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
• Identifier: 45D1069527 . This is a "CLIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: L166 . This is a "FIRSTCARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 45D1015603 . This is a "CLIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 72922010 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
• Identifier: 7187034 . This is a "COLLEGE OF AMERICAN PATHOLOGISTS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 7201511 . This is a "COLLEGE OF AMERICAN PATHOLOGISTS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 0075KP . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 1646044-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".