Provider Demographics
NPI:1174992036
Name:MORISETTE, MATTHEW ALEXANDER (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALEXANDER
Last Name:MORISETTE
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 1:2 LAZY W RD
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-3315
Mailing Address - Country:US
Mailing Address - Phone:253-306-9054
Mailing Address - Fax:
Practice Address - Street 1:1060 GAFFNEY RD. #7440
Practice Address - Street 2:USA MEDDAC-AK / ATTN: MCUC-MMD-QM (CREDENTIALS)
Practice Address - City:FT. WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703-7440
Practice Address - Country:US
Practice Address - Phone:907-361-5603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1127047363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant