Provider Demographics
NPI:1396075743
Name:NIELSEN, MATTHEW DEAN (DPM)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DEAN
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 RUSH CREEK PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-9604
Mailing Address - Country:US
Mailing Address - Phone:816-455-1155
Mailing Address - Fax:816-455-1161
Practice Address - Street 1:550 RUSH CREEK PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-9604
Practice Address - Country:US
Practice Address - Phone:816-455-1155
Practice Address - Fax:816-455-1161
Is Sole Proprietor?:No
Enumeration Date:2010-01-07
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC005995213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery