MEDICARE: MATTHEW J MERZLOCK PA-C

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	363A00000X	Physician Assistant	PA-553	ID

General Provider Information

NPI Number	:	1316985229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW J MERZLOCK PA-C

Provider Business Mailing Address
First Line	:	3360 WASHINGTON PKWY STE 1
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-8333
Country	:	US
Telephone Number	:	208-524-3416
Fax Number	:	208-524-3138

Provider Business Practice Location Address
First Line	:	3360 WASHINGTON PKWY STE 1
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-8333
Country	:	US
Telephone Number	:	208-524-3416
Fax Number	:	208-524-3138

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

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	03/12/2013

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