Provider Demographics
NPI:1922315969
Name:LEFEVRE, MATTHEW STEPHEN
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:STEPHEN
Last Name:LEFEVRE
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 1:1960 US HIGHWAY 41 S
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-9795
Mailing Address - Country:US
Mailing Address - Phone:906-226-6531
Mailing Address - Fax:
Practice Address - Street 1:13924 WADAGA RD
Practice Address - Street 2:
Practice Address - City:BARAGA
Practice Address - State:MI
Practice Address - Zip Code:49908-9204
Practice Address - Country:US
Practice Address - Phone:906-275-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2022-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005864363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OP383400021Medicare Oscar/Certification
WI075100115Medicare Oscar/Certification