Healthcare Provider Details

I. General information

NPI: 1871069377
Provider Name (Legal Business Name): MATTHEW IVANYISKY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2018
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16777 MEDICAL CENTER DR
BATON ROUGE LA
70816-3254
US

IV. Provider business mailing address

PO BOX 471
ALBANY LA
70711-0471
US

V. Phone/Fax

Practice location:
  • Phone: 225-761-5200
  • Fax:
Mailing address:
  • Phone: 225-229-6288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number310189
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: