Provider Demographics
NPI:1053065896
Name:MYERS, MATTHEW V (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:V
Last Name:MYERS
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 1:1550 RIVERSIDE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4162
Mailing Address - Country:US
Mailing Address - Phone:904-923-6647
Mailing Address - Fax:904-923-6647
Practice Address - Street 1:1550 RIVERSIDE AVE STE A
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4162
Practice Address - Country:US
Practice Address - Phone:904-923-6647
Practice Address - Fax:904-355-7788
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-10
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115657207N00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty