Provider Demographics
NPI:1639990906
Name:HOLLAND, MATTHEW JAMES
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:HOLLAND
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3810 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1708
Practice Address - Country:US
Practice Address - Phone:260-425-6030
Practice Address - Fax:260-425-6027
Is Sole Proprietor?:No
Enumeration Date:2024-10-21
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN75000197A367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant