Provider Demographics
NPI:1760041636
Name:DETTRA, MATTHEW ROBERT (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ROBERT
Last Name:DETTRA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:455 PENNSYLVANIA AVE STE 127
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:19034-3409
Mailing Address - Country:US
Mailing Address - Phone:215-793-9755
Mailing Address - Fax:
Practice Address - Street 1:455 PENNSYLVANIA AVE STE 127
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:19034-3409
Practice Address - Country:US
Practice Address - Phone:215-793-9755
Practice Address - Fax:215-412-3587
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical