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:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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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 1:500 W THOMAS RD STE 800
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4217
Practice Address - Country:US
Practice Address - Phone:602-406-1234
Practice Address - Fax:602-406-6368
Is Sole Proprietor?:No
Enumeration Date:2008-11-10
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ4337363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant