Provider Demographics
NPI:1275995516
Name:BROCKWAY, MATTHEW DUANE
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DUANE
Last Name:BROCKWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 HIGHWAY 6 W
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52246-2209
Mailing Address - Country:US
Mailing Address - Phone:319-338-0581
Mailing Address - Fax:
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242
Practice Address - Country:US
Practice Address - Phone:319-384-7354
Practice Address - Fax:319-384-7286
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA120684390200000X
IAD120684367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program