Provider Demographics
NPI:1629591383
Name:STEPHEN, MATTHEW JACOB (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JACOB
Last Name:STEPHEN
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 1:7248 MAIDSTONE PL
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-6630
Mailing Address - Country:US
Mailing Address - Phone:443-220-7690
Mailing Address - Fax:
Practice Address - Street 1:12 SHREVE LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-4066
Practice Address - Country:US
Practice Address - Phone:443-220-7690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA54572363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant