Basic Information
| Provider Information | |||||||||
| NPI: | 1720025737 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKINLEY | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5901 HARPER DR | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871093587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058238556 | ||||||||
| FaxNumber: | 5058238555 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 SPUCE ST | ||||||||
| Address2: | |||||||||
| City: | ESPANOLA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875323456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057537111 | ||||||||
| FaxNumber: | 5057534438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 98-115 | NM | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | NM | MEDICAID |