Provider Demographics
NPI:1699792176
Name:HALL, MATT (RN,PA-C)
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:HALL
Suffix:
Gender:M
Credentials:RN,PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 KIMOLE LN
Mailing Address - Street 2:A-4
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1491
Mailing Address - Country:US
Mailing Address - Phone:517-263-6140
Mailing Address - Fax:517-265-5876
Practice Address - Street 1:901 KIMOLE LN
Practice Address - Street 2:A-4
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1491
Practice Address - Country:US
Practice Address - Phone:517-263-6140
Practice Address - Fax:517-265-5876
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPA40223363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP55075Medicare UPIN
OHPENDINGMedicare ID - Type Unspecified