Provider Demographics
NPI:1114171733
Name:ANDERSON, MATTHEW J (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:ANDERSON
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 1:124 W THOMAS RD STE 103
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4415
Mailing Address - Country:US
Mailing Address - Phone:406-602-4325
Mailing Address - Fax:602-406-4377
Practice Address - Street 1:124 W THOMAS RD STE 103
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4415
Practice Address - Country:US
Practice Address - Phone:602-406-4325
Practice Address - Fax:602-406-4377
Is Sole Proprietor?:No
Enumeration Date:2008-11-10
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4337363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical