Basic Information
| Provider Information | |||||||||
| NPI: | 1487677092 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEVRIES | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | SHAWN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2174 AMOROSA GLN | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920261143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586423120 | ||||||||
| FaxNumber: | 8585524315 | ||||||||
| Practice Location | |||||||||
| Address1: | 3350 LA JOLLA VILLAGE DR | ||||||||
| Address2: | SCI UNIT | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921610002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586423120 | ||||||||
| FaxNumber: | 8585524315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363AM0700X | PA 15775 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.