Provider Demographics
NPI:1255797643
Name:MYAARD, MATTHEW DALE (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DALE
Last Name:MYAARD
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 1:370 N 120TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-2196
Mailing Address - Country:US
Mailing Address - Phone:616-396-5855
Mailing Address - Fax:616-396-5720
Practice Address - Street 1:370 N. 120TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2196
Practice Address - Country:US
Practice Address - Phone:616-396-5855
Practice Address - Fax:616-396-5720
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007659363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG06055030Medicare PIN