Provider Demographics
NPI:1306517271
Name:MATTHEWS, CODY WILLIAM (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:WILLIAM
Last Name:MATTHEWS
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 PLEASANTVIEW LN
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2744
Mailing Address - Country:US
Mailing Address - Phone:208-312-0592
Mailing Address - Fax:
Practice Address - Street 1:243 CHENEY DR W STE 200
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4278
Practice Address - Country:US
Practice Address - Phone:208-736-7422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID60234363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner