Provider Demographics
NPI:1063532125
Name:MATTESON, KRISTIN ANN (DO)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ANN
Last Name:MATTESON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 SWEET HOME RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14228-2792
Mailing Address - Country:US
Mailing Address - Phone:716-838-3188
Mailing Address - Fax:716-838-1297
Practice Address - Street 1:1306 SWEET HOME RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14228-2792
Practice Address - Country:US
Practice Address - Phone:716-838-3188
Practice Address - Fax:716-838-1297
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215890207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02422071Medicaid
NY02422071Medicaid