Provider Demographics
NPI:1326586413
Name:PHILLIPS, MATTHEW DANIEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:DANIEL
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-367-7350
Mailing Address - Fax:208-367-3951
Practice Address - Street 1:1055 N CURTIS ROAD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-367-7350
Practice Address - Fax:208-367-3951
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPA- 1469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant