Provider Demographics
NPI:1417613985
Name:MATTOX, IMAN (RN)
Entity type:Individual
Prefix:
First Name:IMAN
Middle Name:
Last Name:MATTOX
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8080 E CENTRAL AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2367
Mailing Address - Country:US
Mailing Address - Phone:316-686-7327
Mailing Address - Fax:316-686-1557
Practice Address - Street 1:8080 E CENTRAL AVE STE 250
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206
Practice Address - Country:US
Practice Address - Phone:316-686-7327
Practice Address - Fax:316-686-1557
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA95199822163W00000X
KS558169367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse