Healthcare Provider Details

I. General information

NPI: 1205570892
Provider Name (Legal Business Name): MATTHEW RUSSELL REPP PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10494 W THUNDERBIRD BLVD STE 108
SUN CITY AZ
85351-6122
US

IV. Provider business mailing address

18444 N 25TH AVE STE 310
PHOENIX AZ
85023-1266
US

V. Phone/Fax

Practice location:
  • Phone: 866-974-2673
  • Fax: 866-939-2673
Mailing address:
  • Phone: 866-974-2673
  • Fax: 866-939-2673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9012
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: