Provider Demographics
NPI:1578706768
Name:SLEBODA, MATTHEW ALAN (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALAN
Last Name:SLEBODA
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 1:145 POMFRET ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1803
Mailing Address - Country:US
Mailing Address - Phone:860-928-5248
Mailing Address - Fax:860-928-5286
Practice Address - Street 1:145 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1803
Practice Address - Country:US
Practice Address - Phone:860-928-5248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-17
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002248363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant