Provider Demographics
NPI:1477644730
Name:SIDENER, MATT (PA)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:SIDENER
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 1:1255 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0814
Mailing Address - Country:US
Mailing Address - Phone:530-246-2467
Mailing Address - Fax:530-242-9460
Practice Address - Street 1:123 W NORTH BEAR CREEK DR
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-3420
Practice Address - Country:US
Practice Address - Phone:209-722-8161
Practice Address - Fax:209-383-9211
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15066363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00132Medicare UPIN