Provider Demographics
NPI:1750541801
Name:MATLACK, ELIZABETH (PA-C)
Entity type:Individual
Prefix:MISS
First Name:ELIZABETH
Middle Name:
Last Name:MATLACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3300 TILLMAN DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-2030
Mailing Address - Country:US
Mailing Address - Phone:215-633-3456
Mailing Address - Fax:215-245-5941
Practice Address - Street 1:3300 TILLMAN DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-2030
Practice Address - Country:US
Practice Address - Phone:215-633-3456
Practice Address - Fax:215-245-5941
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000538L363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP34999Medicare UPIN