Provider Demographics
NPI:1487677092
Name:DEVRIES, MATTHEW SHAWN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:SHAWN
Last Name:DEVRIES
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 1:2174 AMOROSA GLN
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-1143
Mailing Address - Country:US
Mailing Address - Phone:858-642-3120
Mailing Address - Fax:858-552-4315
Practice Address - Street 1:3350 LA JOLLA VILLAGE DR
Practice Address - Street 2:SCI UNIT
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0002
Practice Address - Country:US
Practice Address - Phone:858-642-3120
Practice Address - Fax:858-552-4315
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 15775363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical