Individual
MATTHEW WADE BLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
607 W MAIN ST, GRANGEVILLE, ID 83530-1345
(208) 983-1700
(208) 983-4665
Mailing address
607 W MAIN ST, GRANGEVILLE, ID 83530-1345
(208) 983-1700
(208) 983-4665
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA-2620
ID
Other
Enumeration date
08/29/2022
Last updated
10/25/2023
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