Provider Demographics
NPI:1760460257
Name:DELLER, MATTHEW (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:DELLER
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 1:38935 ANN ARBOR RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3354
Mailing Address - Country:US
Mailing Address - Phone:734-632-0175
Mailing Address - Fax:734-632-0182
Practice Address - Street 1:33155 ANNAPOLIS ST
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2405
Practice Address - Country:US
Practice Address - Phone:734-467-4042
Practice Address - Fax:734-467-5500
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003936363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
11712508OtherCAQH
Q24594233Medicare PIN
11712508OtherCAQH
N86630013Medicare PIN