Provider Demographics
NPI:1356476212
Name:ORMOND-MATLOCK, LINDA K (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:K
Last Name:ORMOND-MATLOCK
Suffix:
Gender:F
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 1:2402 JOSSMAN RD
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-8205
Mailing Address - Country:US
Mailing Address - Phone:242-627-7128
Mailing Address - Fax:
Practice Address - Street 1:3399 POLLOCK RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8393
Practice Address - Country:US
Practice Address - Phone:810-603-0170
Practice Address - Fax:810-603-2370
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002154363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP1715001Medicare ID - Type UnspecifiedPA-C