Provider Demographics
NPI:1811154131
Name:EMMONS, MATTHEW JAMES
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JAMES
Last Name:EMMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:MATTHEW
Other - Middle Name:JAMES
Other - Last Name:EMMONS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:5568 S FORT APACHE RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-3602
Mailing Address - Country:US
Mailing Address - Phone:623-399-8606
Mailing Address - Fax:623-399-9958
Practice Address - Street 1:5568 S FORT APACHE RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-3602
Practice Address - Country:US
Practice Address - Phone:623-399-8609
Practice Address - Fax:623-399-9958
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7922111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ125978OtherMEDICARE GROUP PTAN
AZZ125916OtherMEDICARE PTAN