Provider Demographics
NPI:1639582596
Name:LEE, MATTHEW S (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:LEE
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 1:2723 S 7TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-3558
Mailing Address - Country:US
Mailing Address - Phone:812-238-1730
Mailing Address - Fax:812-242-1565
Practice Address - Street 1:2723 S 7TH ST STE A
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-3558
Practice Address - Country:US
Practice Address - Phone:812-232-8164
Practice Address - Fax:812-234-6391
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001669A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN147180014Medicare PIN