Provider Demographics
NPI:1225037211
Name:BUREAU, MATTHEW P (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:P
Last Name:BUREAU
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 1:70 LINCOLN STREET, MILL 6
Mailing Address - Street 2:BATES MILL DERMATOLOGY, PLLC
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240
Mailing Address - Country:US
Mailing Address - Phone:207-795-7540
Mailing Address - Fax:207-795-7528
Practice Address - Street 1:70 LINCOLN STREET, MILL 6
Practice Address - Street 2:BATES MILL DERMATOLOGY, PLLC
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240
Practice Address - Country:US
Practice Address - Phone:207-795-7540
Practice Address - Fax:207-795-7528
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103496363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0219PAMedicaid
NC970030187OtherRAILROAD MEDICARE
NC2757287AMedicare PIN
SC0219PAMedicaid