Provider Demographics
NPI:1821037268
Name:TRIPP, MATTHEW ALLEN (PA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALLEN
Last Name:TRIPP
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1848
Mailing Address - Country:US
Mailing Address - Phone:231-727-5211
Mailing Address - Fax:231-727-4571
Practice Address - Street 1:905 E COLBY ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:MI
Practice Address - Zip Code:49461
Practice Address - Country:US
Practice Address - Phone:231-728-5910
Practice Address - Fax:231-728-5918
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002724363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI7481013OtherMEDICARE PTAN
MIMI7481013OtherMEDICARE PTAN
MI0N85740003Medicare ID - Type Unspecified