Provider Demographics
NPI:1124414693
Name:RAINBOLT, MATTHEW PRESTON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:PRESTON
Last Name:RAINBOLT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 51131
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-1131
Mailing Address - Country:US
Mailing Address - Phone:337-349-6708
Mailing Address - Fax:
Practice Address - Street 1:3619 DESERT ROSE LN
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86404-1748
Practice Address - Country:US
Practice Address - Phone:337-349-6708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-12
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6039363A00000X
NC0010-05706363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant