Provider Demographics
NPI:1770981888
Name:HENNIGAN, MATTHEW THOMAS
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:HENNIGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7590 MIRAMAR RD STE C
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4232
Mailing Address - Country:US
Mailing Address - Phone:858-549-4255
Mailing Address - Fax:
Practice Address - Street 1:7590 MIRAMAR RD STE C
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4232
Practice Address - Country:US
Practice Address - Phone:858-549-4255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-05
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09532363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant