Provider Demographics
NPI:1912407180
Name:PAUL, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PAUL
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:PO BOX 3024
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-3024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1784 UINTA WAY UNIT E2
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-7685
Practice Address - Country:US
Practice Address - Phone:435-604-0160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8452730-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant