Healthcare Provider Details

I. General information

NPI: 1477644730
Provider Name (Legal Business Name): MATT SIDENER P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 W NORTH BEAR CREEK DR
MERCED CA
95348-3420
US

IV. Provider business mailing address

1255 LIBERTY ST
REDDING CA
96001-0814
US

V. Phone/Fax

Practice location:
  • Phone: 209-722-8161
  • Fax: 209-383-9211
Mailing address:
  • Phone: 530-246-2467
  • Fax: 530-242-9460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15066
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: