Provider Demographics
NPI:1235324237
Name:THIBDEAU, MATTHEW L (RPA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:L
Last Name:THIBDEAU
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:300 EXEMPLA CIR
Mailing Address - Street 2:SUITE 360
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-3397
Mailing Address - Country:US
Mailing Address - Phone:303-689-6560
Mailing Address - Fax:303-689-6550
Practice Address - Street 1:300 EXEMPLA CIR
Practice Address - Street 2:SUITE 360
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-3397
Practice Address - Country:US
Practice Address - Phone:303-689-6560
Practice Address - Fax:303-689-6550
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA-3205363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO97708585Medicaid
CO97708585Medicaid