Provider Demographics
NPI:1487005161
Name:MATOLKA, PATRICK (PA)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:MATOLKA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-783-3110
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:35 EMPIRE STATE BLVD
Practice Address - Street 2:
Practice Address - City:CASTLETON
Practice Address - State:NY
Practice Address - Zip Code:12033-9777
Practice Address - Country:US
Practice Address - Phone:518-477-2167
Practice Address - Fax:518-477-5182
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY019753363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04493041Medicaid
NY04493041Medicaid