Provider Demographics
NPI:1376102707
Name:NAVARRO, MATTHEW THOMAS (PA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:THOMAS
Last Name:NAVARRO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:4864 JACKSON ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-6400
Practice Address - Country:US
Practice Address - Phone:318-330-7000
Practice Address - Fax:318-330-7591
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA320077363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant