Provider Demographics
NPI:1386156537
Name:FELIX, MATTHEW DANIEL (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DANIEL
Last Name:FELIX
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 1:825 W BERRY ST APT 4
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-3979
Mailing Address - Country:US
Mailing Address - Phone:917-941-4505
Mailing Address - Fax:
Practice Address - Street 1:1141 ROSE AVE
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662-3241
Practice Address - Country:US
Practice Address - Phone:559-891-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-27
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55088363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55088OtherPA-C STATE LICENSE