Provider Demographics
NPI:1003699265
Name:MATTAN, SARAH ANNE (PA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:ANNE
Last Name:MATTAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 LEAHY ST STE 315A
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18621 E 9 MILE RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-1953
Practice Address - Country:US
Practice Address - Phone:586-944-0099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2024-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012142390200000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1003699265Medicaid