Provider Demographics
NPI:1366941247
Name:MATTY, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:MATTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25090 WOODWARD AVE APT 536
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1084
Mailing Address - Country:US
Mailing Address - Phone:248-631-6691
Mailing Address - Fax:
Practice Address - Street 1:24661 COOLIDGE HWY
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1449
Practice Address - Country:US
Practice Address - Phone:248-206-3497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-06
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008561363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant