Provider Demographics
NPI:1467161620
Name:MATOVICH, ABIGAIL (PA-C)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:MATOVICH
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 1:447 WEALTHY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-6002
Mailing Address - Country:US
Mailing Address - Phone:260-415-3228
Mailing Address - Fax:
Practice Address - Street 1:3700 52ND ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-9637
Practice Address - Country:US
Practice Address - Phone:616-656-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-16
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011407363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant