Provider Demographics
NPI:1003325937
Name:IVIE, MATTHEW FRANK (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:FRANK
Last Name:IVIE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 E 1400 N
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-5143
Mailing Address - Country:US
Mailing Address - Phone:208-206-9631
Mailing Address - Fax:
Practice Address - Street 1:267 N CANYON DR
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-5500
Practice Address - Country:US
Practice Address - Phone:208-934-4433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical