Individual
MR. JAMES LEE MATTINGLY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
5141 BROADWAY, NEW YORK, NY 10034-1159
(212) 305-9876
(212) 305-8980
Mailing address
622 W 168TH ST, NEW YORK, NY 10032-3720
(212) 305-9878
(212) 305-8980
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
126000
MO
367500000X
Certified Registered Nurse Anesthetist
Primary
635864
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100388350B
—
MO
01
—
28264022
MO BCBS NUMBER
MO
01
—
430069965
MO RR MEDICARE NUMBER
MO
05
—
915831309
—
MO
Enumeration date
05/24/2006
Last updated
03/07/2023
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