Basic Information
| Provider Information | |||||||||
| NPI: | 1073536561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANKIST | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6374 | ||||||||
| Address2: | |||||||||
| City: | MARIANNA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324476374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8503261918 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4970 HIGHWAY 90 | ||||||||
| Address2: | |||||||||
| City: | MARIANNA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324466802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507185620 | ||||||||
| FaxNumber: | 8507185670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 03/14/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP2899592 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 302183100 | 05 | FL | MEDICAID | Y6876Z | 01 | FL | BCBS | OTHER |