Provider Demographics
NPI:1982791810
Name:BERRIA, MATTHEW JOSEPH (PA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:BERRIA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 NW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-5040
Mailing Address - Country:US
Mailing Address - Phone:208-452-6556
Mailing Address - Fax:541-216-6557
Practice Address - Street 1:1100 NW 12TH ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-5040
Practice Address - Country:US
Practice Address - Phone:208-452-6556
Practice Address - Fax:541-216-6557
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00573363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1040302OtherPACIFIC SOURCE
ID805031400Medicaid
ID805031400Medicaid