Healthcare Provider Details

I. General information

NPI: 1114171733
Provider Name (Legal Business Name): MATTHEW J ANDERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2008
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 W THOMAS RD STE 103
PHOENIX AZ
85013-4415
US

IV. Provider business mailing address

124 W THOMAS RD STE 103
PHOENIX AZ
85013-4415
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-4325
  • Fax: 602-406-4377
Mailing address:
  • Phone: 406-602-4325
  • Fax: 602-406-4377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4337
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number4337
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: