Basic Information
| Provider Information | |||||||||
| NPI: | 1235392663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHORTLE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 768 | ||||||||
| Address2: | |||||||||
| City: | CLIFTON PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120650768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183835450 | ||||||||
| FaxNumber: | 5183834223 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 S MANNING BLVD | ||||||||
| Address2: | @ ST PETER'S HOSPITAL ER DEPT. | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122081707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183835450 | ||||||||
| FaxNumber: | 5183834223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2008 | ||||||||
| LastUpdateDate: | 07/07/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | P65457 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P65457 | 01 | NY | TEMP NYS LICENSE | OTHER |