Provider Demographics
NPI:1801391594
Name:PANYA, MATVEH (PA-C)
Entity Type:Individual
Prefix:
First Name:MATVEH
Middle Name:
Last Name:PANYA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:MATVEH
Other - Middle Name:
Other - Last Name:CHERNYAEV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1440 DUCKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-1451
Mailing Address - Country:US
Mailing Address - Phone:612-435-7380
Mailing Address - Fax:
Practice Address - Street 1:1440 DUCKWOOD DR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122
Practice Address - Country:US
Practice Address - Phone:612-435-7380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12684363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical