Healthcare Provider Details

I. General information

NPI: 1629058805
Provider Name (Legal Business Name): KANE MATTHEW DEEM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 GRANT AVE
GARDNERVILLE NV
89410-7824
US

IV. Provider business mailing address

1460 SOUTH CURRY STREET SUITE 100
CARSON CITY NV
89703
US

V. Phone/Fax

Practice location:
  • Phone: 775-445-7220
  • Fax:
Mailing address:
  • Phone: 775-883-3336
  • Fax: 775-883-0877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: