Provider Demographics
NPI:1700492782
Name:CHAVEZ, MATTHEW KENYON (RN)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:KENYON
Last Name:CHAVEZ
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 BACA AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88435-2435
Mailing Address - Country:US
Mailing Address - Phone:505-785-2270
Mailing Address - Fax:
Practice Address - Street 1:520 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-3720
Practice Address - Country:US
Practice Address - Phone:505-966-1600
Practice Address - Fax:505-966-1265
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-72482163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool