Basic Information
| Provider Information | |||||||||
| NPI: | 1538640214 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOUIS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | WESTVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080931428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6099709698 | ||||||||
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| Practice Location | |||||||||
| Address1: | 218 SUNSET RD | ||||||||
| Address2: | |||||||||
| City: | WILLINGBORO | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080461110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098352900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2018 | ||||||||
| LastUpdateDate: | 08/22/2018 | ||||||||
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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 | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.