Provider Demographics
NPI:1295854651
Name:MATT, SHAWN PATRICK
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:PATRICK
Last Name:MATT
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:PO BOX 880
Mailing Address - Street 2:
Mailing Address - City:ST IGNATIUS
Mailing Address - State:MT
Mailing Address - Zip Code:59865
Mailing Address - Country:US
Mailing Address - Phone:406-745-3525
Mailing Address - Fax:406-745-2437
Practice Address - Street 1:308 MISSION DRIVE
Practice Address - Street 2:
Practice Address - City:ST IGNATIUS
Practice Address - State:MT
Practice Address - Zip Code:59865
Practice Address - Country:US
Practice Address - Phone:406-745-3525
Practice Address - Fax:406-745-2437
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT5817183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician