Provider Demographics
NPI:1356880470
Name:PTACK, MATTHEW ALLEN (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALLEN
Last Name:PTACK
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 1:9650 GROSS POINT RD STE 2900
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1214
Mailing Address - Country:US
Mailing Address - Phone:847-866-7846
Mailing Address - Fax:866-954-5787
Practice Address - Street 1:9650 GROSS POINT RD STE 2900
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076
Practice Address - Country:US
Practice Address - Phone:847-866-7846
Practice Address - Fax:866-954-5787
Is Sole Proprietor?:No
Enumeration Date:2017-02-22
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006139363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant