Provider Demographics
NPI:1265451884
Name:MATTHEWS, ALISSA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:MARIE
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 N. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:CEDAR SPRINGS,
Mailing Address - State:MI
Mailing Address - Zip Code:49319
Mailing Address - Country:US
Mailing Address - Phone:616-696-2020
Mailing Address - Fax:616-696-4860
Practice Address - Street 1:261 N. MAIN STREET
Practice Address - Street 2:
Practice Address - City:CEDAR SPRINGS,
Practice Address - State:MI
Practice Address - Zip Code:49319
Practice Address - Country:US
Practice Address - Phone:616-696-2020
Practice Address - Fax:616-696-4860
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002704363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00307608OtherMETRA UNITED HEALTH
MI1018850OtherMCCLAREN HEALTH PLAN
MI564652Medicare UPIN
MIP14740001Medicare PIN