Provider Demographics
NPI:1235464181
Name:STANICH, MATTHEW ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ALAN
Last Name:STANICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 E SPRUCE AVE STE 101A
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3378
Mailing Address - Country:US
Mailing Address - Phone:559-437-5610
Mailing Address - Fax:
Practice Address - Street 1:1360 E SPRUCE AVE STE 101A
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3378
Practice Address - Country:US
Practice Address - Phone:559-437-5610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-09
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA115379207L00000X
AZ49006207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ169871Medicare PIN