Provider Demographics
NPI:1770546194
Name:DUNDON, MATTHEW R (PAC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:DUNDON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 E SHERMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1878
Mailing Address - Country:US
Mailing Address - Phone:231-733-1326
Mailing Address - Fax:231-830-2764
Practice Address - Street 1:1440 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1878
Practice Address - Country:US
Practice Address - Phone:231-733-1326
Practice Address - Fax:231-830-2764
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004276363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
0N94170OtherMEDICARE GROUP PROVIDER #
N94170001Medicare UPIN