Provider Demographics
NPI:1265719868
Name:ROSSOMANDO, MATTHEW RYAN (PA-C)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:RYAN
Last Name:ROSSOMANDO
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 1:9955 BRICEWOOD HL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-1991
Mailing Address - Country:US
Mailing Address - Phone:908-295-1011
Mailing Address - Fax:
Practice Address - Street 1:1310 MCCULLOUGH AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212
Practice Address - Country:US
Practice Address - Phone:210-757-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5487363A00000X
NJ25MP00263900363AM0700X
TXPA12799363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical