Provider Demographics
NPI:1790743268
Name:SPIVEY, MATTHEW JAMES
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JAMES
Last Name:SPIVEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5702 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-2808
Mailing Address - Country:US
Mailing Address - Phone:701-772-3745
Mailing Address - Fax:
Practice Address - Street 1:1200 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4036
Practice Address - Country:US
Practice Address - Phone:701-780-5270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR27666367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered