Healthcare Provider Details

I. General information

NPI: 1437903499
Provider Name (Legal Business Name): MATTHEW BOONE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2024
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 N MAIN ST
CEDARVILLE OH
45314-8501
US

IV. Provider business mailing address

251 N MAIN ST
CEDARVILLE OH
45314-8501
US

V. Phone/Fax

Practice location:
  • Phone: 937-684-6856
  • Fax:
Mailing address:
  • Phone: 937-684-6856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.010330RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: