Basic Information
| Provider Information | |||||||||
| NPI: | 1013681451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATSON | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 E THOMPSON ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191253211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105067336 | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 S BRYN MAWR AVE | ||||||||
| Address2: | |||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190103121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4843373000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2021 | ||||||||
| LastUpdateDate: | 08/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MA062685 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.