Provider Demographics
NPI:1972547404
Name:JOHNSON, MATTHEW T (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:T
Last Name:JOHNSON
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 1:92 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7228
Mailing Address - Country:US
Mailing Address - Phone:207-885-0011
Mailing Address - Fax:
Practice Address - Street 1:92 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7228
Practice Address - Country:US
Practice Address - Phone:207-885-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-703363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME241390099Medicaid
NH30336259Medicaid
MEP00616756Medicare PIN
MEP19940Medicare UPIN
MEAP136402Medicare PIN
MEAP136401Medicare PIN
MEAP136404Medicare PIN
MEP00928490Medicare PIN
MEAP136403Medicare PIN
MEAP1364Medicare PIN