Individual
MR. MATTHEW D. PROBST
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
2020 7TH ST, LAS VEGAS, NM 87701-4958
(505) 434-0119
(877) 553-1272
Mailing address
117 CAMINO DE VIDA STE 300, SANTA ROSA, NM 88435-2267
(575) 472-4311
(877) 651-0289
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA2003-0043
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
60950277
—
NM
01
—
NM400319
MEDICARE PTAN
NM
Enumeration date
08/31/2005
Last updated
02/23/2023
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