Provider Demographics
NPI:1437584356
Name:MATKIN, RUSSELL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:
Last Name:MATKIN
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 1:3430 IRBY DR APT 509
Mailing Address - Street 2:APT 509
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-7656
Mailing Address - Country:US
Mailing Address - Phone:501-733-0724
Mailing Address - Fax:
Practice Address - Street 1:3430 IRBY DR APT 509
Practice Address - Street 2:APT 509
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-7656
Practice Address - Country:US
Practice Address - Phone:501-733-0724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-498363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant