Provider Demographics
NPI:1205006822
Name:FERNANDEZ, MATTHEW R (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:R
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:410 SAYBROOK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4780
Mailing Address - Country:US
Mailing Address - Phone:860-685-8940
Mailing Address - Fax:860-685-8944
Practice Address - Street 1:410 SAYBROOK RD STE 100
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4780
Practice Address - Country:US
Practice Address - Phone:860-685-8940
Practice Address - Fax:860-685-8944
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002064363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical