Provider Demographics
NPI:1215423504
Name:DOLAN, MATTHEW JAMES (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:DOLAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:111 E WISCONSIN AVE STE 2000
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-4809
Mailing Address - Country:US
Mailing Address - Phone:414-290-6720
Mailing Address - Fax:414-290-6755
Practice Address - Street 1:1726 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303
Practice Address - Country:US
Practice Address - Phone:414-290-6720
Practice Address - Fax:414-290-6755
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI4493-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant