Basic Information
| Provider Information | |||||||||
| NPI: | 1285306423 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAUBACH | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 S LOOP RD | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593012663 | ||||||||
| FaxNumber: | 8598177848 | ||||||||
| Practice Location | |||||||||
| Address1: | 4355 FERGUSON DR | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452455136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132322663 | ||||||||
| FaxNumber: | 8598177848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2021 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50.006827RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.