1780024554 NPI number — MATTHEW M DANELLA PA-C

Table of content: MATTHEW M DANELLA PA-C (NPI 1780024554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780024554 NPI number — MATTHEW M DANELLA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DANELLA
Provider First Name:
MATTHEW
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780024554
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 HIGH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAKEFIELD
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02879-3103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-789-1422
Provider Business Mailing Address Fax Number:
401-789-1422

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1706 MEDICAL BLVD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
NAPLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34110-1417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-593-3500
Provider Business Practice Location Address Fax Number:
239-593-3505
Provider Enumeration Date:
06/26/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA00709 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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