Provider Demographics
NPI:1316048721
Name:MATHEWS-HALMRAST, RAE ELLEN
Entity type:Individual
Prefix:
First Name:RAE
Middle Name:ELLEN
Last Name:MATHEWS-HALMRAST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 25TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6104
Mailing Address - Country:US
Mailing Address - Phone:701-280-2212
Mailing Address - Fax:701-271-1023
Practice Address - Street 1:2301 25TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6104
Practice Address - Country:US
Practice Address - Phone:701-280-2212
Practice Address - Fax:701-271-1023
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND297225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND51245Medicaid
ND51245Medicaid