Provider Demographics
NPI:1275547143
Name:PHARIS, MATTHEW (PA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:PHARIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 W 40TH ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-4010
Mailing Address - Country:US
Mailing Address - Phone:512-459-8753
Mailing Address - Fax:512-483-6807
Practice Address - Street 1:1010 W 40TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-4010
Practice Address - Country:US
Practice Address - Phone:512-459-8753
Practice Address - Fax:512-483-6807
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04125363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX185889601Medicaid
TX8N7134OtherBCBS OF TEXAS
TX74-1796484OtherTAX ID NUMBER
TX8N7134OtherBCBS OF TEXAS
TXQ20282Medicare UPIN