Provider Demographics
NPI:1114983616
Name:NETTLETON, MATTHEW L (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
Last Name:NETTLETON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 COLONY BOULEVARD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15717-7971
Mailing Address - Country:US
Mailing Address - Phone:724-459-9111
Mailing Address - Fax:724-459-7856
Practice Address - Street 1:25 COLONY BOULEVARD
Practice Address - Street 2:SUITE 102
Practice Address - City:BLAIRSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15717-7971
Practice Address - Country:US
Practice Address - Phone:724-459-9111
Practice Address - Fax:724-459-7856
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD422459207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH95645Medicare UPIN
PAD73945Medicare PIN