Provider Demographics
NPI:1871069377
Name:IVANYISKY, MATTHEW (PA-C)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:IVANYISKY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 471
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:LA
Mailing Address - Zip Code:70711-0471
Mailing Address - Country:US
Mailing Address - Phone:225-229-6288
Mailing Address - Fax:
Practice Address - Street 1:16777 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-3254
Practice Address - Country:US
Practice Address - Phone:225-761-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA310189363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant