Provider Demographics
NPI:1033108667
Name:STACK, MATTHEW A (PA C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:STACK
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 1:420 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-2445
Mailing Address - Country:US
Mailing Address - Phone:810-257-3705
Mailing Address - Fax:989-629-8145
Practice Address - Street 1:420 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2445
Practice Address - Country:US
Practice Address - Phone:810-257-3705
Practice Address - Fax:989-629-8145
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003961363A00000X
MI6301007939103T00000X
AZ2782363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0852900260OtherBCBSM
AZ762246Medicaid
AZP00140431OtherRAILROAD
NM50155318OtherMEDICAID
MI0852900260OtherBCBSM
AZP00140431OtherRAILROAD
NM50155318OtherMEDICAID