Provider Demographics
NPI:1992525976
Name:MATA, HAYLIE ASHTYN
Entity type:Individual
Prefix:
First Name:HAYLIE
Middle Name:ASHTYN
Last Name:MATA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HAYLIE
Other - Middle Name:ASHTYN
Other - Last Name:MCGOWAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:50 E 2040 RD
Mailing Address - Street 2:
Mailing Address - City:BOSWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74727-9385
Mailing Address - Country:US
Mailing Address - Phone:580-920-5870
Mailing Address - Fax:
Practice Address - Street 1:50 E 2040 RD
Practice Address - Street 2:
Practice Address - City:BOSWELL
Practice Address - State:OK
Practice Address - Zip Code:74727-9385
Practice Address - Country:US
Practice Address - Phone:580-920-5870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK220582363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily