Provider Demographics
NPI:1053305474
Name:PROBST, MATTHEW D (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:D
Last Name:PROBST
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:117 CAMINO DE VIDA STE 300
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88435-2267
Mailing Address - Country:US
Mailing Address - Phone:575-472-4311
Mailing Address - Fax:877-651-0289
Practice Address - Street 1:2020 7TH ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4958
Practice Address - Country:US
Practice Address - Phone:505-434-0119
Practice Address - Fax:877-553-1272
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2003-0043363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM60950277Medicaid
NMNM400319OtherMEDICARE PTAN