Provider Demographics
NPI:1407395213
Name:LAND, MATTHEW ROBERT (PA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ROBERT
Last Name:LAND
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 1:331 SIJAN AVE
Mailing Address - Street 2:
Mailing Address - City:WHITEMAN AFB
Mailing Address - State:MO
Mailing Address - Zip Code:65305
Mailing Address - Country:US
Mailing Address - Phone:660-687-6066
Mailing Address - Fax:
Practice Address - Street 1:331 SIJAN AVE
Practice Address - Street 2:
Practice Address - City:WHITEMAN AFB
Practice Address - State:MO
Practice Address - Zip Code:65305
Practice Address - Country:US
Practice Address - Phone:660-687-6066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-14
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant