Provider Demographics
NPI:1659130490
Name:ALTHEIDE, MATTHEW (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:ALTHEIDE
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 1:16095 NIPPET LN
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-1112
Mailing Address - Country:US
Mailing Address - Phone:951-488-2397
Mailing Address - Fax:
Practice Address - Street 1:16095 NIPPET LN
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92551-1112
Practice Address - Country:US
Practice Address - Phone:951-488-2397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE018059146N00000X
CAPA64114363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical