Basic Information
| Provider Information | |||||||||
| NPI: | 1689151680 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | KEITH | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1848 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494431848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316727000 | ||||||||
| FaxNumber: | 3134327758 | ||||||||
| Practice Location | |||||||||
| Address1: | 3570 HENRY ST STE 120 | ||||||||
| Address2: | |||||||||
| City: | NORTON SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494414576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316727000 | ||||||||
| FaxNumber: | 2317285041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2018 | ||||||||
| LastUpdateDate: | 08/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN.CNP.023142 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 4704370943 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.