Provider Demographics
NPI:1326801606
Name:EBBIGHAUSEN, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:EBBIGHAUSEN
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 1:432 JOSEPH STREET EXT
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102-2352
Mailing Address - Country:US
Mailing Address - Phone:603-499-2506
Mailing Address - Fax:
Practice Address - Street 1:24 ORCHARD VIEW DR STE 2
Practice Address - Street 2:
Practice Address - City:LONDONDERRY
Practice Address - State:NH
Practice Address - Zip Code:03053-3376
Practice Address - Country:US
Practice Address - Phone:603-782-9081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH092967-23363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily