Provider Demographics
NPI:1639121916
Name:DUBIE, MATT J
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:J
Last Name:DUBIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 JACKSON ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-8144
Mailing Address - Country:US
Mailing Address - Phone:920-426-2211
Mailing Address - Fax:920-426-2231
Practice Address - Street 1:500 S OAKWOOD RD
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7944
Practice Address - Country:US
Practice Address - Phone:920-223-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI106026030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44312900Medicaid
WI002045485Medicare ID - Type Unspecified
WI003571535Medicare ID - Type Unspecified