Provider Demographics
NPI:1770990335
Name:KANELOS, MATTHEW (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:KANELOS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11307 N LINDEN RD
Mailing Address - Street 2:B
Mailing Address - City:CLIO
Mailing Address - State:MI
Mailing Address - Zip Code:48420
Mailing Address - Country:US
Mailing Address - Phone:810-564-7995
Mailing Address - Fax:
Practice Address - Street 1:11307 N LINDEN RD
Practice Address - Street 2:B
Practice Address - City:CLIO
Practice Address - State:MI
Practice Address - Zip Code:48420
Practice Address - Country:US
Practice Address - Phone:810-564-7995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007022363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant