Healthcare Provider Details

I. General information

NPI: 1174992465
Provider Name (Legal Business Name): MATTHEW EARHART PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2015
Last Update Date: 12/23/2022
Certification Date: 12/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9980 CENTRAL PARK BLVD N STE 222
BOCA RATON FL
33428-1704
US

IV. Provider business mailing address

9980 CENTRAL PARK BLVD N STE 222
BOCA RATON FL
33428-1704
US

V. Phone/Fax

Practice location:
  • Phone: 561-558-8898
  • Fax: 561-558-8868
Mailing address:
  • Phone: 561-558-8898
  • Fax: 561-558-8868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPAT 9108938
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA 9108938
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9108938
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: