Provider Demographics
NPI:1134520042
Name:NEDWICKI, MATTHEW (PA-C)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:NEDWICKI
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 1:1416 ERICKSON RD
Mailing Address - Street 2:
Mailing Address - City:BOYNE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49712-9199
Mailing Address - Country:US
Mailing Address - Phone:313-618-6824
Mailing Address - Fax:
Practice Address - Street 1:4771 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48210-3247
Practice Address - Country:US
Practice Address - Phone:313-897-2600
Practice Address - Fax:313-897-2424
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine