Provider Demographics
NPI:1376610097
Name:GARRIS, MATTHEW D (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:D
Last Name:GARRIS
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 1:407 S. 19TH ST
Mailing Address - Street 2:
Mailing Address - City:BLAIR
Mailing Address - State:NE
Mailing Address - Zip Code:68008
Mailing Address - Country:US
Mailing Address - Phone:402-533-2223
Mailing Address - Fax:531-301-6272
Practice Address - Street 1:407 S. 19TH ST
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:NE
Practice Address - Zip Code:68008
Practice Address - Country:US
Practice Address - Phone:402-533-2223
Practice Address - Fax:531-301-6272
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE900363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE38785OtherBLUE CROSS BLUE SHIELD
NE38785OtherBLUE CROSS BLUE SHIELD