Provider Demographics
NPI:1104814177
Name:MORRISON, MATTHEW JOHN (PA-C)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JOHN
Last Name:MORRISON
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 1:2805 S ASCIANO CT
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-6322
Mailing Address - Country:US
Mailing Address - Phone:386-566-0584
Mailing Address - Fax:
Practice Address - Street 1:1690 DUNLAWTON AVE STE 210
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-8980
Practice Address - Country:US
Practice Address - Phone:386-763-4920
Practice Address - Fax:386-763-4939
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9100655363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290535300Medicaid