| Doctor Name: | MR. MICHAEL LEROY MATTESON |
| NPI Number: | 1033386115 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PA C |
| License Number: | 385000710 |
| Business Practice Address: | 305 W Jackson St Suite 105 Carbondale, IL - 629011474 |
| Business Phone Number: | 6185362565 |
| Business Fax Number: | 6185362835 |
| Mailing Address: | Po Box 1105, INDIANAPOLIS |
| State: | IN |
| Postal Code: | 462061105 |
| Phone Number: | 6184575200 |
| Fax Number: | 6183514821 |
| NPI Enumeration Date: | 05/08/2008 |
| NPI Last Update Date: | 10/13/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AS0400X |
| License Number: | 385000710 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Surgical |
| Taxonomy Definition: | |