Healthcare Provider Details

I. General information

NPI: 1477024503
Provider Name (Legal Business Name): MATTHEW G. DATLOW MSPAS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 06/28/2023
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 W AMERICAN AVE
ORACLE AZ
85623-6089
US

IV. Provider business mailing address

PO BOX 10097
CASA GRANDE AZ
85130-0020
US

V. Phone/Fax

Practice location:
  • Phone: 520-896-2092
  • Fax:
Mailing address:
  • Phone: 520-836-3446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: