Individual
GENNAYA LYNN MATTISON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
350 MILLER ST SE STE 200, SALEM, OR 97302-4272
(503) 400-3434
Mailing address
350 MILLER ST SE STE 200, SALEM, OR 97302-4272
(503) 400-3434
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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