Healthcare Provider Details

I. General information

NPI: 1912663006
Provider Name (Legal Business Name): MATTHEW MOYER PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2021
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE
DANVILLE PA
17822-9569
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-7149
  • Fax: 570-271-7165
Mailing address:
  • Phone: 570-271-6144
  • Fax: 570-271-6578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA062890
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA062890
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: