Healthcare Provider Details

I. General information

NPI: 1710390950
Provider Name (Legal Business Name): MATTHEW DAVID PARADISO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47601 GRAND RIVER AVE PROVIDENCE PARK HOSPITAL
NOVI MI
48374
US

IV. Provider business mailing address

1601 N VERMONT AVE
ROYAL OAK MI
48067-1461
US

V. Phone/Fax

Practice location:
  • Phone: 248-465-4100
  • Fax:
Mailing address:
  • Phone: 586-524-9837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601007034
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: