Provider Demographics
NPI:1558455311
Name:MATTHYSSE, AMBER B (MS PA-C)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:B
Last Name:MATTHYSSE
Suffix:
Gender:F
Credentials:MS PA-C
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:L
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS PA-C
Mailing Address - Street 1:1673 GEZON PKWY SW
Mailing Address - Street 2:STE A
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9520
Mailing Address - Country:US
Mailing Address - Phone:616-243-3376
Mailing Address - Fax:616-243-3377
Practice Address - Street 1:1673 GEZON PKWY SW STE A
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9520
Practice Address - Country:US
Practice Address - Phone:616-243-3376
Practice Address - Fax:616-243-3377
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003436363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI11296005OtherPTAN
MI1047265OtherPA CERTIFICATION
MI5601003436OtherPA LICENSE
1153321047OtherPECOS ID
MI1558455311Medicaid