MEDICARE: MR. MATTHEW D. PROBST PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA2003-0043	NM

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	NM400319	OTHER	NM	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053305474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW D. PROBST PA-C

Provider Business Mailing Address
First Line	:	117 CAMINO DE VIDA STE 300
Second Line	:
City	:	SANTA ROSA
State	:	NM
Zip	:	88435-2267
Country	:	US
Telephone Number	:	575-472-4311
Fax Number	:	877-651-0289

Provider Business Practice Location Address
First Line	:	2020 7TH ST
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4958
Country	:	US
Telephone Number	:	505-434-0119
Fax Number	:	877-553-1272

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2005
Last Update Date	:	02/23/2023

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