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General NPI Number Information
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NPI Number | 1184181166
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Entity Type | Individual
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Provider Name | MATTHEW MATTY PA-C
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Gender | Male
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Dates
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Enumeration Date | 02/26/2019
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Last Update Date | 03/13/2019
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Provider Practice Location Address
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Address Line | 23832 SOUTHFIELD RD
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City | SOUTHFIELD
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State | MI
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Zip | 48075-8000
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Country | US
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Telephone | 248-569-2600
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Fax |
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Provider Business Mailing Address
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Address Line | 2873 GREENLAWN AVE
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City | COMMERCE TOWNSHIP
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State | MI
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Zip | 48382-3543
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Country | US
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Telephone | 248-686-6863
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5601009033
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License Number State | MI
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