Provider Demographics
NPI:1679801484
Name:PERRY, MATTHEW (CRNA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PERRY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 GORMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-3181
Mailing Address - Country:US
Mailing Address - Phone:304-636-3300
Mailing Address - Fax:
Practice Address - Street 1:812 GORMAN AVE
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3181
Practice Address - Country:US
Practice Address - Phone:304-636-3300
Practice Address - Fax:304-637-3435
Is Sole Proprietor?:No
Enumeration Date:2009-12-07
Last Update Date:2022-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH331469367500000X
FLAPRN9492405367500000X
WV64303367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH331469OtherLICNESE
WV3910000863Medicaid