Provider Demographics
NPI:1699286443
Name:MATROS, THOMAS ANTHONE TAYLOR (LPN)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:ANTHONE TAYLOR
Last Name:MATROS
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 19TH AVE N STE 300
Mailing Address - Street 2:
Mailing Address - City:SOUTH ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55075-1301
Mailing Address - Country:US
Mailing Address - Phone:651-471-9038
Mailing Address - Fax:
Practice Address - Street 1:710 19TH AVE N STE 300
Practice Address - Street 2:
Practice Address - City:SOUTH ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55075-1301
Practice Address - Country:US
Practice Address - Phone:651-471-9038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL730901164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN$$$$$$$$$Medicaid