Provider Demographics
NPI:1740303296
Name:GOULD, MATTHEW (PA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GOULD
Suffix:
Gender:M
Credentials:PA
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 3037
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-3037
Mailing Address - Country:US
Mailing Address - Phone:229-985-3320
Mailing Address - Fax:229-891-9079
Practice Address - Street 1:1 MAGNOLIA CT
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6764
Practice Address - Country:US
Practice Address - Phone:229-985-3320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002749363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA327453101AMedicaid
GA327453101AMedicaid