Basic Information
| Provider Information | |||||||||
| NPI: | 1609141902 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE # MC845 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164866790 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1009 W GREEN ST | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490581710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163913139 | ||||||||
| FaxNumber: | 6163913044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2012 | ||||||||
| LastUpdateDate: | 02/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 5601006321 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.