Provider Demographics
NPI:1215091525
Name:NEDDO, MATTHEW MEMMOTT (PA-C, MPAS)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:MEMMOTT
Last Name:NEDDO
Suffix:
Gender:M
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5080 SPECTRUM DR STE 1200W
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4624
Mailing Address - Country:US
Mailing Address - Phone:972-364-8000
Mailing Address - Fax:
Practice Address - Street 1:2500 S LAKE PARK BLVD
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-8218
Practice Address - Country:US
Practice Address - Phone:801-902-4238
Practice Address - Fax:801-266-6916
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT373676-1206363AM0700X
UT3736761206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT373676-1206OtherSTATE LICENSE