Provider Demographics
NPI:1447468590
Name:VAN TINE, MATTHEW PAUL (PA-C)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:PAUL
Last Name:VAN TINE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4239 FARNAM ST STE 100
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2858
Mailing Address - Country:US
Mailing Address - Phone:402-552-2320
Mailing Address - Fax:402-552-2330
Practice Address - Street 1:4239 FARNAM ST STE 100
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-2858
Practice Address - Country:US
Practice Address - Phone:402-552-2320
Practice Address - Fax:402-552-2330
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003493363A00000X
NE1437363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant