Provider Demographics
NPI:1093201667
Name:DACOSTA, MATTHEW JACOB (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JACOB
Last Name:DACOSTA
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 1:111 FRANKLIN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:RI
Mailing Address - Zip Code:02809-2327
Mailing Address - Country:US
Mailing Address - Phone:508-264-1979
Mailing Address - Fax:
Practice Address - Street 1:180 CORLISS ST STE B
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-2602
Practice Address - Country:US
Practice Address - Phone:401-793-8400
Practice Address - Fax:401-793-8402
Is Sole Proprietor?:No
Enumeration Date:2018-07-07
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01269363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant