Provider Demographics
NPI:1174578892
Name:HOLBROOK, MATTHEW (PA C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:HOLBROOK
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:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:WHITESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41858
Mailing Address - Country:US
Mailing Address - Phone:606-633-4823
Mailing Address - Fax:606-633-1874
Practice Address - Street 1:464 KY HIGHWAY 699
Practice Address - Street 2:
Practice Address - City:CORNETTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41731-8749
Practice Address - Country:US
Practice Address - Phone:606-476-2593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA808363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95004289Medicaid
P94577Medicare UPIN
KY95004289Medicaid