Provider Demographics
NPI:1174551873
Name:PLUMMER, MATTHEW J (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:PLUMMER
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 1:29928 SAINT SIMON ST
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-9562
Mailing Address - Country:US
Mailing Address - Phone:251-583-3101
Mailing Address - Fax:
Practice Address - Street 1:29928 SAINT SIMON ST
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-9562
Practice Address - Country:US
Practice Address - Phone:251-583-3101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA465363AS0400X, 363A00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL122073Medicaid
AL511-07322OtherBCBS
AL009937279Medicaid
AL122065Medicaid
AL122069Medicaid
AL122739Medicaid
AL511-07320OtherBCBS
AL511-07321OtherBCBS
AL122071Medicaid
AL511-07323OtherBCBS
AL1174551873OtherTRICARE SOUTH
AL122073Medicaid
AL122739Medicaid
AL051558667Medicare PIN