Provider Demographics
NPI:1033108667
Name:STACK, MATTHEW A (PA C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:STACK
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 1:121 N PINE RIVER ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:MI
Mailing Address - Zip Code:48847-1039
Mailing Address - Country:US
Mailing Address - Phone:989-287-0662
Mailing Address - Fax:989-629-8145
Practice Address - Street 1:121 N PINE RIVER ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:MI
Practice Address - Zip Code:48847-1039
Practice Address - Country:US
Practice Address - Phone:989-287-0662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007939103T00000X
AZ2782363A00000X
363AM0700X
MI5601003961363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00140431OtherRAILROAD
MI0852900260OtherBCBSM
AZ762246Medicaid
NM50155318OtherMEDICAID
MI0852900260OtherBCBSM
AZP00140431OtherRAILROAD
NM50155318OtherMEDICAID