Provider Demographics
NPI:1942266150
Name:DEROSBY, MATTHEW J (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:DEROSBY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 WHITING HILL RD STE 300
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1006
Mailing Address - Country:US
Mailing Address - Phone:207-989-0550
Mailing Address - Fax:207-989-0551
Practice Address - Street 1:234 STATE ST
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-1519
Practice Address - Country:US
Practice Address - Phone:207-989-0550
Practice Address - Fax:207-989-0551
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA534363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME205060099Medicaid
MEAP0793Medicare ID - Type Unspecified
ME205060099Medicaid