Provider Demographics
NPI:1235401761
Name:PIVOVAR, MATTHEW THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:PIVOVAR
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 1:201 RABERN CT
Mailing Address - Street 2:APT 1111
Mailing Address - City:BELTON
Mailing Address - State:TX
Mailing Address - Zip Code:76513-1913
Mailing Address - Country:US
Mailing Address - Phone:808-226-8124
Mailing Address - Fax:
Practice Address - Street 1:36000 DARNALL LOOP
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-618-8768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1102211363A00000X
ORPA181331363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1102211OtherNCCPA ID #