Provider Demographics
NPI:1912699547
Name:EZERNACK, MATTHEW QUINN
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:QUINN
Last Name:EZERNACK
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 1:2923 SUMMER PLACE DR
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-0758
Mailing Address - Country:US
Mailing Address - Phone:337-309-0925
Mailing Address - Fax:
Practice Address - Street 1:4080 NELSON RD STE 500
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-2440
Practice Address - Country:US
Practice Address - Phone:337-494-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11530208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation