Provider Demographics
NPI:1821321969
Name:MATJE, AMANDA FRANCES (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:FRANCES
Last Name:MATJE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:FRANCES
Other - Last Name:PAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:107 E OAK AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1818
Practice Address - Country:US
Practice Address - Phone:928-779-7880
Practice Address - Fax:928-779-7895
Is Sole Proprietor?:No
Enumeration Date:2009-09-08
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4520363A00000X
363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ466775Medicaid
AZZ177170Medicare PIN
AZ5550830006OtherMEDICARE NSC ANTHEM
AZ5550830001OtherMEDICARE NSC SCW
AZ5550830008OtherMEDICARE NSC SWV
AZ5550830009OtherMEDICARE NSC AZ NORTH
AZ5550830003OtherMEDICARE NSC PEORIA
AZ5550830010OtherMEDICARE NSC GILBERT