Healthcare Provider Details

I. General information

NPI: 1255797643
Provider Name (Legal Business Name): MATTHEW DALE MYAARD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2016
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 N. 120TH AVE
HOLLAND MI
49424-2196
US

IV. Provider business mailing address

370 N 120TH AVE
HOLLAND MI
49424-2196
US

V. Phone/Fax

Practice location:
  • Phone: 616-396-5855
  • Fax: 616-396-5720
Mailing address:
  • Phone: 616-396-5855
  • Fax: 616-396-5720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601007659
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: