Provider Demographics
NPI:1639198526
Name:SHUTE, MATTHEW STEPHEN (PA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:STEPHEN
Last Name:SHUTE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5112 WEST TAFT ROAD
Mailing Address - Street 2:SUITE L
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088
Mailing Address - Country:US
Mailing Address - Phone:315-452-2500
Mailing Address - Fax:315-452-2510
Practice Address - Street 1:4000 MEDICAL CENTER DRIVE SUITE 104
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6635
Practice Address - Country:US
Practice Address - Phone:315-663-0059
Practice Address - Fax:315-663-0123
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011106363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02300011106Medicaid
NY02870006Medicaid
NY02300011106Medicaid
NYP00395549Medicare PIN
NYQ71579Medicare UPIN