Provider Demographics
NPI:1356009369
Name:MULCAHY, MATTHEW CODY (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CODY
Last Name:MULCAHY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14842 SHARON AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-9409
Mailing Address - Country:US
Mailing Address - Phone:616-502-2190
Mailing Address - Fax:
Practice Address - Street 1:1400 MERCY DR STE 100
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1833
Practice Address - Country:US
Practice Address - Phone:231-733-1326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010963363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant