Provider Demographics
NPI:1184181166
Name:MATTY, MATTHEW (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MATTY
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 1:2873 GREENLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48382-3543
Mailing Address - Country:US
Mailing Address - Phone:248-686-6863
Mailing Address - Fax:
Practice Address - Street 1:23832 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-8000
Practice Address - Country:US
Practice Address - Phone:248-569-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009033363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant