Provider Demographics
NPI:1457364705
Name:CADWALLADER, MATTHEW LEONARD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:LEONARD
Last Name:CADWALLADER
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 1:424 W PRICE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-4406
Mailing Address - Country:US
Mailing Address - Phone:215-713-9595
Mailing Address - Fax:
Practice Address - Street 1:1401 BETHLEHEM PIKE
Practice Address - Street 2:
Practice Address - City:FLOURTOWN
Practice Address - State:PA
Practice Address - Zip Code:19031-1904
Practice Address - Country:US
Practice Address - Phone:215-233-1001
Practice Address - Fax:215-233-9749
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002594L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA055087JW9Medicare ID - Type Unspecified
PAS83509Medicare UPIN