Provider Demographics
NPI:1205889086
Name:LAND, MATTHEW V (PA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:V
Last Name:LAND
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:910 E HOUSTON ST
Practice Address - Street 2:STE 330
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8369
Practice Address - Country:US
Practice Address - Phone:903-525-7995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04590363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01583815OtherRAIL ROAD MEDICARE
TXP00430280OtherRR MEDICARE
TX187968603Medicaid
TX8EY674OtherBCBS
TX187968602Medicaid
TX75-2616977-091OtherTRICARE
TXP00430280OtherRR MEDICARE
TX187968603Medicaid