Basic Information
| Provider Information | |||||||||
| NPI: | 1386156537 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FELIX | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 W BERRY ST APT 4 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468023979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9179414505 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1141 ROSE AVE | ||||||||
| Address2: | |||||||||
| City: | SELMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936623241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5598911000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2017 | ||||||||
| LastUpdateDate: | 10/27/2017 | ||||||||
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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 | 363A00000X | 55088 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 55088 | 01 | CA | PA-C STATE LICENSE | OTHER |