MEDICARE: MR. MATTHEW MEMMOTT NEDDO PA-C, MPAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	373676-1206	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	373676-1206	OTHER	UT	STATE LICENSE

General Provider Information

NPI Number	:	1215091525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW MEMMOTT NEDDO PA-C, MPAS

Provider Business Mailing Address
First Line	:	5080 SPECTRUM DR STE 1200W
Second Line	:
City	:	ADDISON
State	:	TX
Zip	:	75001-4624
Country	:	US
Telephone Number	:	972-364-8000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 S LAKE PARK BLVD
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84120-8218
Country	:	US
Telephone Number	:	801-902-4238
Fax Number	:	801-266-6916

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	11/16/2023

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