Provider Demographics
NPI:1093706368
Name:BERTUS, MATTHEW S (PA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:BERTUS
Suffix:
Gender:M
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:PO BOX 268919
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8919
Mailing Address - Country:US
Mailing Address - Phone:405-608-3800
Mailing Address - Fax:405-608-3838
Practice Address - Street 1:4050 W MEMORIAL RD
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8382
Practice Address - Country:US
Practice Address - Phone:405-608-3800
Practice Address - Fax:405-608-3838
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK861363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK10011900AMedicaid
OK349532203Medicare ID - Type Unspecified
OKS66586Medicare UPIN
OKOKA100690Medicare PIN
OKOKA102012Medicare PIN
OK10011900AMedicaid