Basic Information
| Provider Information | |||||||||
| NPI: | 1477550762 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VONMATTHIESSEN | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | WAGNER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 LIVERMORE STREET | ||||||||
| Address2: | |||||||||
| City: | YELLOW SPRINGS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377670147 | ||||||||
| FaxNumber: | 9706419017 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 LIVERMORE STREET | ||||||||
| Address2: | |||||||||
| City: | YELLOW SPRINGS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377670147 | ||||||||
| FaxNumber: | 9706419017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 12/23/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 38431 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35.076986 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2208659 | 05 | OH | MEDICAID | 70076341 | 05 | CO | MEDICAID |