Provider Demographics
NPI:1063996288
Name:CHERNIKOVICH, MATTHEW STEVEN (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:STEVEN
Last Name:CHERNIKOVICH
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 1:6284 TWIN OAKS DR APT 2222
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-8329
Mailing Address - Country:US
Mailing Address - Phone:630-247-0513
Mailing Address - Fax:
Practice Address - Street 1:5134 N NEVADA AVE STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-8699
Practice Address - Country:US
Practice Address - Phone:719-598-5698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0005468363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant