Provider Demographics
NPI:1720228935
Name:WARK, MATTHEW G (PAC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:G
Last Name:WARK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 N TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:CO
Mailing Address - Zip Code:81230-2296
Mailing Address - Country:US
Mailing Address - Phone:970-641-1456
Mailing Address - Fax:970-641-4461
Practice Address - Street 1:711 N TAYLOR ST
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2243
Practice Address - Country:US
Practice Address - Phone:970-641-1456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-27
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004357363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant