Basic Information
| Provider Information | |||||||||
| NPI: | 1215969951 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOONAN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PAAA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100254 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326100254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522738610 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326101473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522738610 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 09/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 135.0000036 | VT | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 367H00000X | 003913 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 367H00000X | AA498 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 103736800 | 05 | FL | MEDICAID | 598163770B | 05 | GA | MEDICAID |