Provider Demographics
NPI:1316985229
Name:MERZLOCK, MATTHEW J (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:MERZLOCK
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 1:3360 WASHINGTON PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8333
Mailing Address - Country:US
Mailing Address - Phone:208-524-3416
Mailing Address - Fax:208-524-3138
Practice Address - Street 1:3360 WASHINGTON PKWY STE 1
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8333
Practice Address - Country:US
Practice Address - Phone:208-524-3416
Practice Address - Fax:208-524-3138
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-553363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDQ45199Medicare UPIN
1666996Medicare Oscar/Certification