Provider Demographics
NPI:1063284305
Name:ANDERSON, MATAEO JOHN
Entity type:Individual
Prefix:
First Name:MATAEO
Middle Name:JOHN
Last Name:ANDERSON
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 1:1332 N YALE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74115-5361
Mailing Address - Country:US
Mailing Address - Phone:405-287-9711
Mailing Address - Fax:
Practice Address - Street 1:1332 N YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74115-5361
Practice Address - Country:US
Practice Address - Phone:405-287-9711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program