Provider Demographics
NPI:1205570892
Name:REPP, MATTHEW RUSSELL (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RUSSELL
Last Name:REPP
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:18444 N 25TH AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1266
Mailing Address - Country:US
Mailing Address - Phone:866-974-2673
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:10494 W THUNDERBIRD BLVD STE 108
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-6122
Practice Address - Country:US
Practice Address - Phone:866-974-2673
Practice Address - Fax:866-939-2673
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9012363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant