Provider Demographics
NPI:1487132163
Name:TWICHELL, MATTHEW JAROD (CRNA, MSN)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JAROD
Last Name:TWICHELL
Suffix:
Gender:M
Credentials:CRNA, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10061 N BAIRD AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93730-5100
Mailing Address - Country:US
Mailing Address - Phone:775-691-0453
Mailing Address - Fax:
Practice Address - Street 1:2823 FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721
Practice Address - Country:US
Practice Address - Phone:559-459-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95076357163WC0200X
CA95000952367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care MedicineGroup - Single Specialty