Provider Demographics
NPI:1164110995
Name:MAIA, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MAIA
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 1:14801 LEMOYNE BLVD APT 359
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-7035
Mailing Address - Country:US
Mailing Address - Phone:228-935-3252
Mailing Address - Fax:
Practice Address - Street 1:1000 ACCESS RD # 4
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567-4485
Practice Address - Country:US
Practice Address - Phone:228-935-3252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-28
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA010128359171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider