Provider Demographics
NPI:1336360304
Name:WILLARD, MATTHEW (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:WILLARD
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:PO BOX 37028
Mailing Address - Street 2:
Mailing Address - City:TOKSOOK BAY
Mailing Address - State:AK
Mailing Address - Zip Code:99637
Mailing Address - Country:US
Mailing Address - Phone:907-427-3500
Mailing Address - Fax:907-427-3526
Practice Address - Street 1:1 TOKSOOK BAY SUB-REGIONAL CLINIC
Practice Address - Street 2:
Practice Address - City:TOKSOOK BAY
Practice Address - State:AK
Practice Address - Zip Code:99637
Practice Address - Country:US
Practice Address - Phone:907-543-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK629363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDA0196Medicaid
AKMDA0196Medicaid