Provider Demographics
NPI:1710390950
Name:PARADISO, MATTHEW DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:PARADISO
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 1:1601 N VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1461
Mailing Address - Country:US
Mailing Address - Phone:586-524-9837
Mailing Address - Fax:
Practice Address - Street 1:47601 GRAND RIVER AVE
Practice Address - Street 2:PROVIDENCE PARK HOSPITAL
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374
Practice Address - Country:US
Practice Address - Phone:248-465-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007034363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical