Basic Information
| Provider Information | |||||||||
| NPI: | 1720228935 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WARK | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 N TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | GUNNISON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812302296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706411456 | ||||||||
| FaxNumber: | 9706414461 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 N TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | GUNNISON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812302243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706411456 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2009 | ||||||||
| LastUpdateDate: | 05/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA.0004357 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.