Provider Demographics
NPI:1699468140
Name:MATTESON, ABIGAIL
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:MATTESON
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 1:10 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MOHAWK
Mailing Address - State:NY
Mailing Address - Zip Code:13407-1011
Mailing Address - Country:US
Mailing Address - Phone:315-679-7965
Mailing Address - Fax:315-717-0266
Practice Address - Street 1:103 N CAROLINE ST
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-1716
Practice Address - Country:US
Practice Address - Phone:315-717-0264
Practice Address - Fax:315-717-0266
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010517332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier