Provider Demographics
NPI:1619799335
Name:PROVOST, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PROVOST
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 1:5401 S WHITE MOUNTAIN RD STE B
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7849
Mailing Address - Country:US
Mailing Address - Phone:928-537-8479
Mailing Address - Fax:
Practice Address - Street 1:5401 S WHITE MOUNTAIN RD STE B
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7849
Practice Address - Country:US
Practice Address - Phone:928-537-8479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHADE15739237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist