Basic Information
| Provider Information | |||||||||
| NPI: | 1336360304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLARD | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 37028 | ||||||||
| Address2: | |||||||||
| City: | TOKSOOK BAY | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074273500 | ||||||||
| FaxNumber: | 9074273526 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 TOKSOOK BAY SUB-REGIONAL CLINIC | ||||||||
| Address2: | |||||||||
| City: | TOKSOOK BAY | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 09/07/2010 | ||||||||
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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 | 363A00000X | 629 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | MDA0196 | 05 | AK | MEDICAID |