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Individual
GENNAYA LYNN MATTISON
Active
Individual
GENNAYA LYNN MATTISON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
Taxonomy
Speciality
Code
Description
License number
State
208200000X
Plastic Surgery Physician
198745
OR
2086S0122X
Plastic and Reconstructive Surgery Physician
Primary
198745
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
198745
MEDICAL LICENSE
OR
Enumeration date
04/29/2014
Last updated
05/10/2021
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